NBHS1303 Clinical Pharmacology & Toxicology - Smay19 (MREP) PDF

NBHS1303
Clinical Pharmacology and Toxicology
Copyright © Open University Malaysia (OUM)

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NBHS1303
CLINICAL
PHARMACOLOGY
AND TOXICOLOGY
Prof Dr Faridah Hashim
Dr Aini Ahmad
Yee Bit Lian
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" Copyright © Open University Malaysia (OUM)
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Table of Contents
Course Guide ixăxiv
Topic 1 Core Concepts of Pharmacology 1

1.1 Core Concepts of Pharmacology Terminology 2
1.2 Routes of Medication Administration 4
1.3 Classification of Therapeutic Agents/Drugs 8
1.4 Prescription and Over-the-counter Drugs 12
1.5 Legal and Ethical Issues in Drug Administration 14
1.6 Healthcare ProvidersÊ Role in Health Education of 19
Medication Administration
Summary 19
Key Terms 20
References 21
Topic 2 Pharmacology and Adverse Effects of Drugs 22

2.1 Assessment of Patients Related to Drug Administration 23
2.1.1 Assessment of Patient Problems 26
2.1.2 Setting Goals and Outcomes for Drug Administration 28
2.1.3 Key Interventions for Drug Administration 28
2.1.4 Evaluating the Effects of Drug Administration 29
2.2 Pharmacotherapy across the Lifespan 30
2.2.1 Drug Administration during Childhood 30
2.2.2 Drug Administration during Adulthood 31
2.3 Principles of Drug Administration 33
2.4 Medication Errors and Risk Management 37
2.4.1 What are the Factors Contributing to Medication 38
Errors?
2.4.2 The Impact of Medication Errors 40
2.4.3 Strategies for Reducing Medication Errors 41
2.4.4 Providing Patient Education for Medication Usage 43
2.4.5 Risk Management 44
2.5 Adverse Effect of Drugs 45
2.5.1 Primary Actions 45
2.5.2 Secondary Actions 45
2.5.3 Hypersensitivity 45

iv  TABLE OF CONTENTS
2.6 Toxicity 46
2.6.1 Liver Injury 46
2.6.2 Renal Injury 46
Summary 47
Key Terms 48
References 49
Topic 3 Pharmacotherapy for Conditions of the Cardiovascular System 50

3.1 Specific Precautions for Frequent Medications Used in 51
Common Cardiovascular System Disorders
3.2 Drugs for Heart Failure and Arrhythmias 54
3.3 Drugs for Disorders of Blood Coagulation 61
3.4 Drugs for Coronary Artery Disease and Stroke 63
3.5 Drugs for Shock 66
Summary 69
Key Terms 70
References 70
Topic 4 Pharmacotherapy for Conditions of the Respiratory System 71

4.1 Specific Precautions for Medications Related to 72
Respiratory System Disorders
4.2 Drugs for Chronic Obstructive Airway/Pulmonary 73
Disease (COPD)
4.3 Drugs for Inflammation, Fever and Allergies 79
4.3.1 Drugs to Treat Asthma 80
4.3.2 Drugs to Treat Allergy-induced Rhinitis 84
4.3.3 Drugs to Treat Fever and Inflammation 84
4.4 Safety Alerts for Medications of Respiratory System in 85
All Age Groups
4.4.1 Management for Children 85
4.4.2 Drug Therapy for Pregnant and Breastfeeding 87
Mothers with Respiratory Problems
4.4.3 Management of Drug Therapy for the Elderly 88
Summary 90
Key Terms 90
References 91

TABLE OF CONTENTS  v
Topic 5 Pharmacotherapy for Drugs of Gastrointestinal, Endocrine 92

and Other Conditions
5.1 Special Precautions for Medications Related to Specific 93
Systems
5.1.1 Gastrointestinal System 93
5.1.2 Endocrine System 99
5.2 Drugs for Bacterial, Viral, Fungal, Protozoan and Helminth 105
Infections
5.3 Drugs for Neoplasia 109
Summary 114
Key Terms 115
References 115

vi  TABLE OF CONTENTS

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COURSE GUIDE
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COURSE GUIDE  ix
COURSE GUIDE DESCRIPTION

You must read this Course Guide carefully from the beginning to the end. It tells
you briefly what the course is about and how you can work your way through the
course material. It also suggests the amount of time you are likely to spend in order
to complete the course successfully. Please refer to the Course Guide as you go
through the course material as it will help you to clarify important study
component or points that you might miss or overlook.
INTRODUCTION
NBHS1303 Clinical Pharmacology and Toxicology is one of the courses offered at
Open University Malaysia (OUM). This course is worth 3 credit hours and should
be covered over 8 to 15 weeks.
COURSE AUDIENCE
This course is specifically offered to learners taking the Bachelor in Medical and
Health Science with Honours programme.
As an open and distance learner, you should be acquainted with learning

independently and being able to optimise the learning modes and environment
available to you. Before you begin this course, please ensure that you have the right
course materials, and understand the course requirements as well as how the
course is conducted.
STUDY SCHEDULE
It is a standard OUM practice the learners accumulate 40 study hours for every
credit hour. As such, for a three credit hours course, you are expected to spend 120
study hours. Table 1 gives an estimation of how the 120 study hours could be
accumulated.
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x  COURSE GUIDE
Table 1: Estimation of Time Accumulation of Study Hours
Study
Study Activities
Hours
Briefly go through the course content and participate in initial discussions 3
Study the module 47
Attend 5 tutorials sessions 10
Participate in online discussion/eForum 20
Revision/Online self-test/Practice past year exam questions 20
Assignment Preparations/Examination 20
TOTAL STUDY HOURS ACCUMULATED 120
COURSE LEARNING OUTCOMES

By the end of this course, you should be able to:
1. Describe pharmacotherapeutics, pharmacokinetics and pharmacodynamics;
2. Discuss the responsibilities of healthcare providers in medication
administration and adverse effects of drugs;
3. Describe the significance of medication errors and risk management;
4. Differentiate the different groups of medications for various systems in the
body; and
5. Analyse the safety precautions for medications related to different body
systems.
COURSE SYNOPSIS
This course is divided into five topics. The synopsis for each topic is listed as
follows:
Topic 1 introduces the core concepts of pharmacology. Medication administration

comes with its own safety precautions as well as responsibilities for the
practitioner. Medication safety is very important to prevent the occurrence of very
harmful and dangerous situations caused by medication errors. In this topic, you
will learn that the healthcare providers must observe the responses including
targets expected after administration of medication, paying particular attention to
the expected outcome of medication and any potential side effects that may occur.

COURSE GUIDE  xi
Topic 2 discusses how the principles of drugs administration is essential to provide

a holistic approach and prevent medication errors. Healthcare providers must
apply the knowledge of appropriate drug administration that caters for different
life spans. The same knowledge should be appreciated by the healthcare providers
in exercising specific precautions for high alert medications to various body
systems. In this topic, you will learn about the importance of the administration of
drugs, adverse effects and the systematic documentation for reporting errors.
Topic 3 explores pharmacotherapy for conditions of the cardiovascular system.

Coronary heart disease remains the number one killer in terms of health-related
problems in Malaysia. This is partly due to the country going through a rapid
development phase whereby the preventive and promotive healthcare facilities
are insufficient to meet the needs of the general population. In this topic, you will
explore various drugs for heart failure, dysrhythmias, blood coagulation
disorders, coronary artery disease and strokes; together with the specific
precautions for medications related to cardiovascular system. The provided
algorithm will be a helpful guide for you as it follows the clinical practice
guidelines.
Topic 4 explains that although some respiratory disorders are due to genetic
disorders, a vast majority of the risk factors are attributed to environmental factors
(such as occupation dusts and pollution), poor habits (tobacco smoking),
vulnerable socioeconomic status, virulent infections and cumulative effects of
oxidative stress. An algorithm based on clinical practice guidelines is provided to
guide you in managing patients with chronic obstructive pulmonary diseases
(COPD) and asthma. In this topic, you will be provided with knowledge on
specific precautions for medications related to common respiratory system
disorders prevalent in different age groups, drugs for COPD, asthma, allergy
rhinitis, fever and inflammation.
Topic 5 adds on to your knowledge on medications for gastrointestinal (GI)

system, common endocrine conditions and other miscellaneous disorders. In this
topic, the discussion on the GI system will be divided into upper and lower GI
tracks. For the endocrine system, the discussion will only focus on diabetes
insipidus (DI), diabetic ketacidosis (DKA) and diabetes mellitus (DM). Separately,
this topic will also briefly explore medications for bacterial, viral, fungal, protozoa
and helminth infections. Lastly, information will be provided on medications for
neoplasia, with an overview of the role of chemotherapy in different strategies for
cancer treatment, namely adjuvant therapy, induction therapy, consolidation
therapy, intensification, maintenance, neoadjuvant therapy and palliative therapy.

xii  COURSE GUIDE
TEXT ARRANGEMENT GUIDE

Before you go through this module, it is important that you note the text
arrangement. Understanding the text arrangement will help you to organise your
study of this course in a more objective and effective way. Generally, the text
arrangement for each topic is as follows:
Learning Outcomes: This section refers to what you should achieve after you have
completely covered a topic. As you go through each topic, you should frequently
refer to these learning outcomes. By doing this, you can continuously gauge your
understanding of the topic.
Self-Check: This component of the module is inserted at strategic locations

throughout the module. It may be inserted after one sub-section or a few sub-
sections. It usually comes in the form of a question. When you come across this
component, try to reflect on what you have already learnt thus far. By attempting
to answer the question, you should be able to gauge how well you have
understood the sub-section(s). Most of the time, the answers to the questions can
be found directly from the module itself.
Activity: Like Self-Check, the Activity component is also placed at various

locations or junctures throughout the module. This component may require you to
solve questions, explore short case studies, or conduct an observation or research.
It may even require you to evaluate a given scenario. When you come across an
Activity, you should try to reflect on what you have gathered from the module
and apply it to real situations. You should, at the same time, engage yourself in
higher order thinking where you might be required to analyse, synthesise and
evaluate instead of only having to recall and define.
Summary: You will find this component at the end of each topic. This component
helps you to recap the whole topic. By going through the summary, you should be
able to gauge your knowledge retention level. Should you find points in the
summary that you do not fully understand, it would be a good idea for you to
revisit the details in the module.
Key Terms: This component can be found at the end of each topic. You should go
through this component to remind yourself of important terms or jargon used
throughout the module. Should you find terms here that you are not able to
explain, you should look for the terms in the module.
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COURSE GUIDE  xiii
References: The References section is where a list of relevant and useful textbooks,
journals, articles, electronic contents or sources can be found. The list can appear
in a few locations such as in the Course Guide (at the References section), at the
end of every topic or at the back of the module. You are encouraged to read or
refer to the suggested sources to obtain the additional information needed and to
enhance your overall understanding of the course.
PRIOR KNOWLEDGE
No prior knowledge required.
ASSESSMENT METHOD
Please refer to myINSPIRE.
REFERENCES
Act 366 Poisons Act 1952 (Revised 1989). Laws of Malaysia. Retrieved from
http://www.pharmacy.gov.my/v2/sites/default/files/document-
upload/poisons-act-1952-act-366.pdf
Adams, M. P., Holland, L. N., & Bostwick, P. M. (2014). Pharmacology for

nurses: A pathophysiological approach (4th ed.). Upper Saddle River, NJ:
Pearson/Prentice Hall.
Aschenbrenner, D. S., & Venable, S. J. (2012). Drug therapy in nursing (4th ed.).
Philadelphia, PA: Lippincott Williams & Wilkins.
Barber, P., Parkes, J., & Blundell, D. (2012). Further essentials of pharmacology for
nurses. Maidenhead, England: Open University Press/McGraw-Hill.
Clayton, B., & Willinganz, M. (2012). Basic pharmacology for nurses (16th ed.).
St. Louis, MO: Elsevier.
Craig, G. P. (2015). Clinical calculations made easy: Solving problems using

dimensional analysis (6th ed.). New York, NY: Wolters Kluwer.
Clinical Practice Guidelines (CPG). (2007). Management of heart failure (2nd ed.).
Malaysia Ministry of Health.

xiv  COURSE GUIDE
Downie, G., Mackenzie, J., Williams, A., & Hind, C. (2008). Pharmacology and
medicines management for nurses (4th ed.). New York, NY: Churchill
Livingstone Elsevier.
Karch, A. M. (2013). Focus on nursing pharmacology (6th ed.). Philadelphia, PA:

Lippincott Williams & Wilkins.
Kee, J. L., Hayes, E. R., & McCuistion, L. E. (2014). Pharmacology: A patient centred
approach. St Louis, MO: Wolters Kluwer.
Ministry of Health Malaysia. (2006). National cardiovascular disease

database (NCVD): Inaugural report of the acute coronary syndrome
(ACS) registry. Retrieved from https://www.malaysianheart.org/files/
9838599049782352004fd.pdf
Ministry of Health Malaysia. (2009). Clinical practice guidelines:

Management of type 2 diabetes mellitus (4th ed.). Retrieved from
http://www.moh.gov.my/attachments/3878.pdf
Ministry of Health Malaysia. (1996). Guidelines on management of adult asthma:

A consensus statement of Malaysian Thoracic Society. The Medical Journal
of Malaysia, 51(1), 114ă128.
Ministry of Health Malaysia. (2009). Clinical practice guidelines: Management

of chronic obstructive pulmonary disease (2nd ed.). Retrieved from
Yeager, J. J., Burchum, J., & Rosenthal, L. (2015). Study guide for LehneÊs
pharmacology for nursing care (9th ed.). St. Louis, MO: Elsevier.
TAN SRI DR ABDULLAH SANUSI (TSDAS)

DIGITAL LIBRARY
The TSDAS Digital Library has a wide range of print and online resources for the
use of its learners. This comprehensive digital library, which is accessible through
the OUM portal, provides access to more than 30 online databases comprising
e-journals, e-theses, e-books and more. Examples of databases available are
EBSCOhost, ProQuest, SpringerLink, Books247, InfoSci Books, Emerald
Management Plus and Ebrary Electronic Books. As an OUM learner, you are
encouraged to make full use of the resources available through this library.

Topic
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" Core Concepts of

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Pharmacology
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" LEARNING OUTCOMES
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" By the end of this topic, you should be able to:
" 1. Define the terms pharmacotherapeutics, pharmacokinetics and
" pharmacodynamics;
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" 2. State the common routes of medication administration;
" 3. Discuss the classifications of drugs according to their basis or origin;
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" 4. Describe prescription and over-the-counter drugs;
" 5. List the 11 rights of medication administration; and
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" 6. Discuss the responsibilities of a healthcare providers in medication
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 INTRODUCTION
The many functions of a healthcare providers include the ability and dexterity to
prepare and administer via the different routes, medications prescribed by a
physician in a safe and timely manner. Medication administration comes with its
own safety precautions as well as responsibilities for the administrator. Among
the responsibilities for patient safety expected of the administrator includes
ensuring that the right medication is administered via the right route and to the
right patient. The administrator must observe the responses, including expected
therapeutic effects, after the administration of the medication, paying particular
attention to the expected outcome of medication, and detecting any potential side
effects that may occur. Medication safety is very important to prevent harmful and
dangerous situations from arising as a result of medication error.

2  TOPIC 1 CORE CONCEPTS OF PHARMACOLOGY
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Pharmacology is a term derived from the Greek words pharmakon, meaning

medicine, and logos which is study, hence it is the study of medicine. It was
officially recognised as a discipline in its own right in 1847. Over the years, this
discipline has advanced and grown in tandem with the technological advances
and research activities related to pharmacology. It has also become more complex
and challenging to cater to new medical conditions being discovered and
diagnosed as clinicians try to find the right pharmacological preparations to
produce the required effects on the patient. Common terminologies associated
with pharmacology are drugs and therapeutic agents.
Therapeutics is concerned with the prevention and cure of diseases as well as

alleviating suffering of the affected person. The meaning of drugs includes the
introduction of substance used as medication in the body for a specific effect.
In this topic, you will learn more on the core concepts related to pharmacology;
classifications of therapeutic agents and their preparations; legal and ethical issues
associated with medication administration; and the healthcare providersÊ roles in
medication administration.
1.1 CORE CONCEPTS OF PHARMACOLOGY

TERMINOLOGY
Now that you have read the introduction to pharmacology, let us consider the
meaning of three important terminologies in pharmacology as follows:
(a) Pharmacotherapeutics or Pharmacotherapy

Describes the application of drugs or therapeutic agents in order to prevent
and cure diseases or medical conditions and provide treatment to alleviate
the suffering of an individual. It is the study of how a prescribed drug
produces the desired effect to the person receiving and using it according to
the indications stated for that prescription, which may either be intended for
curative purposes or to alleviate and prevent suffering from a disease.
(b) Pharmacokinetics
This is a term derived from two words; „pharmaco‰ which means medicine
and „kinetics‰ which means movement. The term denotes the study of the
movement of drugs within the body or the activities of the drugs once it
enters the body until it is discharged from the system. It is also about
the effects of the administered drug while traversing the body system.
The movement of the drugs or phases can be monitored from various
mechanisms of absorption, distribution, metabolism and excretion
happening within the body.

TOPIC 1 CORE CONCEPTS OF PHARMACOLOGY  3
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Importantly for healthcare providers, the application of pharmacokinetics in

medication administration ensures that healthcare providers can anticipate
the actions of the drugs administered and take precautions to prevent any
negative responses related to those drugs. What healthcare providers need
to remember in pharmacokinetics is that at each movement of the drug
through the four phases namely, absorption, distribution, metabolism and
excretion, there are barriers that the drug must overcome before reaching the
targeted cells in order to be effective.
This is where healthcare providers should be able to apply knowledge

related to anatomy and physiology to better comprehend the journey taken
by these drugs to reach the targeted destination. One of the most challenging
barriers faced by drugs in reaching the targeted cells and organs is the
barriers created by the presence of cell membranes. Once the drug has
reached the target cells and released its chemicals, the journey of the
remaining substrate is equally challenging as it has to reach the liver to be
detoxified and then move on to the renal system for excretion.
(c) Pharmacodynamics
Pharmacodynamics is derived from two words; „pharmaco‰, the root word,
meaning medicine, and „dynamics‰ which means the changes brought about
by the responses of the drugs to the body. This depends on additional factors
like drug concentrations in the body and the interactions of drugs on
different individuals.
The understanding of pharmacodynamics assists healthcare providers to

identify changes expected of a drug for different individuals based on dose,
therapeutic index to ensure effective and safe drug administration. This is
where knowledge on pharmacodynamics assists healthcare providers to
anticipate the expected action of the drugs, time taken for the action to be
effective and the possible barriers that prevent it from taking effect. Among
the related knowledge includes differences in the body make up in infants,
adults and the elderly as well as any comorbidities present in an individual.
The time taken for the drug to take effect may be different for different age
groups and the dose administered. That is why dosage of some drugs is
dispensed according to body weight and height or body mass index (BMI) of
the patient.
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Other common terms related to pharmacology are shown in Table 1.1.
Table 1.1: Descriptions of Common Terms Related to Pharmacology
Terms Description
Side effects Known unintended or undesirable effects of a medication.
Adverse Unexpected harm arising from a justified action even when the
reactions correct process was followed.
Adverse event An incident that results in harm to a patient.
Adverse drug Something which may or may not be preventable as a result of drug
event reaction in the body.
Medication Preventable event occurring due to improper safety precautions.
error
1.2 ROUTES OF MEDICATION

ADMINISTRATION
Drugs or medicine are administered via various routes and means to provide
therapeutic relief to a patient. The routes through which medications are
commonly administered can be divided into the three routes shown in Figure 1.1.
Figure 1.1: The three common routes of medication administration
The three routes through which medications are commonly administered are
described as follows:
(a) Topical
Medication that is applied locally to the skin surface or membrane lining of
eye, ear, nose, respiratory tract, urinary tract, vagina and rectum. Examples
of topical medications include the following:
(i) Epicutaneous/transdermal or dermatologic;
(ii) Inhalation, such as asthma medications;

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(iii) Enema or suppositories ă vagina, rectum;
(iv) Eye drops/ophthalmic;
(v) Ear drops/otic; and
(vi) Nasal/intranasal.
(b) Enteral
Includes medications administered via oral, nasogastric and gastrostomy
tubes. Considered the safest route as the medication is administered directly
into the stomach in the following ways:
(i) Oral preparation ă Swallowing tablets, capsules, liquid and drops.
(ii) Oral via mouth, buccal ă Medication placed between the gums and
cheek, or sublingual ă medication placed under tongue.
(iii) Nasogastric or gastrostomy tube ă Any medication prescribed for a

patient who cannot consume them orally may be administered via this
route. Tablets need to be crushed and diluted with water.
(c) Parenteral
Via injection using needles that penetrate into skin layers, subcutaneous
tissue, muscles, veins, arteries, body cavities (intrathecal) and organs
(intracardiac). The procedure is invasive in nature and prone to risk of
infection and other forms of complications. Precautions taken to reduce
chances of complications include the following:
(i) Person administering must adhere to the aseptic technique during

preparation and eventual delivery of injection.
(ii) Identify the appropriate injection delivery instruments, right dose and
right name of medication, right route for delivery and technique for
safe, effective delivery of medication.
(iii) Recognise the right patient and examine the appropriate anatomical
location for injection administration.
(iv) Adhere to proper disposal of used materials and equipment.
Whenever a drug is consumed via the oral route, it will pass through three phases,
described as follows:
(a) Pharmaceutic
This is the dissolution phase where the drug breakdowns as it passes through
the digestive system.

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(b) Pharmacokinetic
As mentioned earlier, this term consists of a combination of two words;
pharmaco meaning medicine and kinetic meaning movement. What happens
is that as the drug traverses the digestive system, it will release its specific
effects on the target organ/system. This means the effects will begin to take
place either in the mouth itself (sublingual, buccal), the stomach or in the
intestines. There are four other processes occurring during this phase and
they are:
(i) Absorption;
(ii) Distribution;
(iii) Metabolism; and
(iv) Excretion.
(c) Pharmacodynamic
Also as clarified earlier, this term includes two words; medicine and
dynamics, which means the changes occurring in the body brought about by
the effect of the drug taken. The result can either be a biologic or physiologic
response. Biologic response means that the drugs work by modifying the
immune system of the body as an enhancer or suppressor. Physiologic
response of drugs simply means how the drugs affect the body and its
system.
Time of Action using Different Routes of Administration

When a drug is administered by other routes like intravenous, subcutaneous or
intramuscular means, the action depends on the barriers the drug needs to
overcome in order to reach the targeted cells and organs for therapeutic effect to
occur. For that reason, the anticipated barriers for the drug reaction from the
different routes have been identified. As an example, for the intravenous route, the
barriers are much less than if a medication was given via the oral route. This means
any drug administered via the intravenous route takes a shorter time for the
therapeutic effect to be observed.
Knowledge on drug action includes the information on the time taken for the
medication or drug to take effect once it is delivered through any of the routes.
Table 1.2 compares the estimated time taken for effects from medication given
through the different routes.
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Table 1.2: Estimated Time Taken for Effects from

Medication Given through Different Routes
Route Time Taken to Take Effect/Action

Intravenous 30 to 60 seconds
Intraosseous 30 to 60 seconds
Endotracheal 2 to 3 minutes
Inhalation 2 to 3 minutes
Sublingual 3 to 5 minutes
Intramuscular 10 to 20 minutes
Subcutaneous 15 to 30 minutes
Rectal 5 to 30 minutes
Ingestion 30 to 90 minutes
Transdermal Varies (minutes to hours)
Health care providers use accepted abbreviations to communicate the directions

and times for drug administration. Abbreviations and written orders related to
medicine administration are as follows:
(a) PRN order ă Drug administered as required by the patientÊs condition, to be

given only when necessary.
(b) ASAP ă Drug should be available for administration as soon as possible, at

least within 30 minutes of written order.
(c) STAT ă Medication is to be given immediately.
(d) Routine orders ă With no accompanying instructions, such as, should be

carried out within two hours of prescription.
(e) Standing order ă Specific to situation, such as, to be given pre-operative or

post operatively.
SELF-CHECK 1.1
1. Define pharmacotherapeutics, pharmacokinetics and

pharmacodynamics.
2. State the three common routes of medication administration.

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ACTIVITY 1.1
Check out the information leaflet in a medicine box purchased or a
specific medicine prescribed to you or a family member. Identify the
variety of information content included in the leaflet. Identify the
subheadings available on the leaflet that indicate the use of the drug,
indications, contraindications, dose and specific precautions. Share your
findings in the myINSPIRE online forum.
1.3 CLASSIFICATION OF THERAPEUTIC

AGENTS/DRUGS
As you may be well aware and have seen at the workplace, there are many
hundreds of drugs available and there are some medications whose names may
only have a difference of one alphabet from the name of another, and even
pronounced almost in a similar way, yet they are prescribed for completely
different purposes. This is because they have different therapeutic functions and
are prepared differently. Often times, this fact can result in confusion and error,
especially when a person tries to decide on the drug based solely on the verbal
pronunciation, as how it is pronounced can be different from how it is actually
spelt as.
With advanced research and development in pharmacology, many more new

drugs will be made available and this may also contribute to many „almost similar
yet different‰ drugs obtainable on the shelf. To minimise the chance of mishaps,
professionals concerned with drug production and control like Pharmacists have
taken precautionary steps to group drugs based on specific classifications or
therapeutic functions. Medications are further classified into the different drug
schedules, which assist users or regulators to categorise and control its distribution
and use.
There are various ways of classifying a drug. An example is to classify drugs

according to their basis or origin such as the following:
(a) Drugs from natural origin can be from herbal, plant, marine or mineral
origin.
(b) Drugs from chemicals as well as natural origin; this is derived from partial
herbal and partial chemicals, like steroid drugs.

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(c) Drugs from chemical synthesis.
(d) Drugs derived from microbial origin, like antibiotics.
(e) Drugs from animal origin like hormones and enzymes.
There are two common types of drug classifications commonly used to categorise
the many thousands of drugs available in the market as shown in Figure 1.2.
Figure 1.2: Types of drug classifications
Let us now learn more about the two types of drug classifications:
(a) Therapeutic Classification

The term therapeutic classification is used to organise the drugs based on
their use in the treatment to cure specific diseases. This term can be simple to
classify as one can classify the drug based on the therapeutic effect it has to
cure a disease. Examples of such classifications are „drugs for treatment of
heart failure‰ or „drugs for hypertension‰. The two groups of drugs
obviously act on the cardiovascular system to produce therapeutic effects.
It must be noted that there are many different drugs that effects the
cardiovascular system, but each drug will have different functions. Table 1.3
provides drug information by therapeutic classification focusing on cardiac
care and drugs affecting the cardiovascular function.
"

"
Table 1.3: Organising Drug Information by Therapeutic Classification
Therapeutic Usefulness of Drug Therapeutic Classification of Drug
Influences blood clotting Anticoagulants
Lowers blood cholesterol Antihyperlipidemics
Lowers blood pressure Antihypertensive
Restores normal cardiac rhythm Antidysrhythmics
Treats angina Antianginals
Source: Adams, Holland and Urban (2011)
(b) Pharmacological Classification

The second term is pharmacological classification. This classification
indicates the way the drug works based on its mechanism of actions,
meaning the way the drug effects the body. The action of the drug on the
body depends on the molecular build, the target tissue and also the body
system that it is supposed to have effect on. One will find that when a drug
is classified by its pharmacological aspect, it is very specific and can also be
complex depending on whether it has to be described by its chemical effect
and name. One also needs to have an understanding of biochemistry and
physiology of the human body to understand the effects of the particular
drug. An example of the pharmacologic classification for hypertension is
presented in Table 1.4.
Table 1.4: Organising Drug Information by Pharmacological Classification
Mechanism of Action of Drug Pharmacological Classification of Drug
Lowers plasma volume Diuretic
Blocks heart calcium channels Calcium channel blocker
Blocks enzyme activity Angiotensin-converting enzyme inhibitor
Blocks hormonal physiologic Adrenergic antagonist/blocker

reactions to stress
Dilates peripheral blood vessels Vasodilator
Source: Adams et al. (2011)

"
Another challenge related to pharmacology as mentioned in the introduction

is getting to remember the names of thousands of drugs available and this
increases yearly. Many drugs are not only identified by a single name, but by three
names; the chemical, generic and trade names.
Let us now learn more about the three types of names of drugs:
(a) The chemical name of a drug follows the standards set by the International
Union of Pure and Applied Chemistry (IUPAC), where the chemical
properties and physical substance of the drug is assigned to a drug. This can
be very complicated and, most times only those involved with production of
the drug will have the opportunity to identify it by its chemical name. The
chemical name clearly describes the nature of the drug, but it can be lengthy,
rendering it difficult to remember or pronounce.
(b) The generic name means a drug which was assigned a name based on the US
Adopted Name Council. Generic names are easier to remember and
healthcare providers must know the generic name of drugs as a prescription
is always written out using generic names.
(c) The trade name usually reflects the name of the drug given by the company
producing or marketing it. Although the generic name and the chemical
contents are similar, a drug may have a different trade name if it is being
manufactured by different companies. For this reason, no prescription
should use the trade name and if a trade name is written, it should also
include the generic name to prevent any confusion or error in identifying the
correct drug.
SELF-CHECK 1.2
1. State the classifications of drugs according to their basis or origin.
2. Describe the characteristics of chemical, generic and trade names.

"
ACTIVITY 1.2
1. For each of the two methods of organising drugs, identify two

examples based on the format presented in Table 1.3 and Table 1.4.
2. List 10 drugs according to their chemical, generic and trade names.
1.4 PRESCRIPTION AND OVER-THE-COUNTER

DRUGS
In this subtopic, we will identify the laws relevant to prescription of drugs,
procuring over-the-counter drugs and handling drug prescriptions. Drugs must
be prescribed by an authorised health personnel.
You need to first know the difference between the term dispensing and
administration:
(a) Dispensing is the act of getting ready the specific medications to be given
which is mostly the responsibility of a pharmacist.
(b) Administration on the other hand is the act of actual giving of the medication
to the person named. The qualified person to perform this procedure can be
a registered healthcare provider, assistant medical officer, physician,
pharmacist or any other healthcare personnel that has been endorsed as
qualified to perform the procedure according to the respective professional
regulations.
In Malaysia, the prescriber must abide to the rules and regulations stipulated by
the Poisons Act (Laws of Malaysia Act 366 Poisons Act 1952 (revised 1989)).
At times, we do find that in the home facility, the individual may self-administer
his/her medication or engage the assistance of a carer to help administer the drug.
This is allowable provided that adequate education and information has been
provided to the client and carer.
Individuals authorised to dispense drugs are as follows:
(a) Registered medical practitioners;
(b) Registered dental surgeons;
(c) Registered pharmacists licensed under Poisons Ordinance Act 1952 to sell
Part I Poisons; and
(d) Registered pharmacists engaged in public hospitals or public institutions.

"
A prescription drug is a drug that requires a drug prescription form. A drug

prescription form is a list that contains the description of a single drug or multiple
drugs to be made available to the named person on the list. It is an official
document where among others:
(a) It has properly designated forms recognised by the organisation issuing it;
(b) Considered legal and binding where the inscription is stated clearly and
legibly and that the date of prescription is written;
(c) The name of the person for whom drug is intended for (spelled correctly);
and
(d) Age and any identification number or patient registration number.

"
Some organisations include a serial number to each prescription slip.
The medication must be legibly written and preferably the generic name is written,
dose, frequency as well as duration for the drug to be taken. The prescriber must
endorse his/her signature as well as stamp the prescription with a valid stamp of
the prescriber that contains his/her registration number and designation.
Sometimes an organisation may require additional signature for specific drugs to
be counter-signed by a higher ranking official before the pharmacist/pharmacy
can issue the drug. Only when the prescription has been duly filled, can the
owner/carer of the prescription get the prescription filled at a healthcare
pharmacist or any other registered pharmacy of choice.
All prescriptions have a validity period of seven days to be filled from the date
stated on the form. In-patients will have their prescription written in the
designated forms provided by the organisation. The drug schedules are made
available in the Poisons Act and drugs classified under certain schedules must be
prescribed by an authorised person.
Drugs that can be bought without a prescription are called „over-the-counter

drugs‰. These drugs are commonly found in any household and considered as
non-poison drugs. Some examples of OTC drugs include lozenges, pastilles,
topical analgesics, topical nasal decongestants and emollients.
SELF-CHECK 1.3
Briefly describe the drugs that can be bought over the counter
without prescription and drugs that require a physicianÊs prescription.

"
ACTIVITY 1.3
Name 10 over-the-counter drugs that you know of.
1.5 LEGAL AND ETHICAL ISSUES IN DRUG

ADMINISTRATION
Every country has its own statutory laws and regulations with regards to control
of drugs. In Malaysia, Act 366, Poisons Act (1952), revised in 1989 is referred to for
all matters pertaining to drugs. Drugs are classified in schedules and it is important
for you to be aware of the drug schedules currently enforced that ensures
compliance to the safekeeping, dispensing and administration of those drugs.
The function of the Act is to regulate the importation, possession, manufacture,

compounding, storage, transport, sale and use of the poisons identified. Anyone
found to have abused any part of the Act shall be liable to legal action covered by
the Act and are punishable by law.
All pharmaceuticals in Malaysia are regulated by Drug Control Authority (DCA)

under the Control of Drugs and Cosmetics Regulations 1984. The following are
some descriptions of the DCA:
(a) The DCA is managed by the Director General of Health, Director of

Pharmaceutical Services, Director of the National Pharmaceutical Control
Laboratory and seven other appointed members.
(b) The main responsibility of the DCA is to ensure the safety, quality and
efficacy of pharmaceuticals in Malaysia.
(c) Some of the duties of the DCA include reviewing registration applications
for drugs and cosmetics; licensing importers, manufacturers and
wholesalers; post-marketing safety surveillance; and adverse drug reaction
(ADR) monitoring.
(d) According to the DCA, „any drug in a pharmaceutical dosage form, intended
to be used, or capable or purported or claimed to be capable of being used
on humans or any animals, whether internally or externally, for a medicinal
purpose‰ is required to be registered with the DCA.

"
The following legal aspects pertaining to drugs or medicine have to be taken into
consideration as well:
(a) Legal issues related to drugs or medicines are controlled by law ă Drug
Control Authority (DCA).
(b) It is illegal to be in possession of controlled drugs such as narcotics and

barbiturates.
(c) Policy relating to „who can give what medication‰ and „double check‰ to
comply.
(d) Healthcare provider who administers is accountable and responsible if the

prescription was improper or wrong.
(e) Narcotics ă policy on storage of empty vials and balance of drug must be
adhered according to the policy in your organisation, state or country.
Procedure for the safekeeping of drug or medicine and their administration

involves the following:
(a) Proper handing over of inventory of scheduled drugs.
(b) Safekeeping of keys ă accountable if missing.
(c) Double check entry ă removal of scheduled drug and balance correct to time
and date.
(d) Ensure all medication trolley locked and kept in safe place.
(e) Never combine drug on own ă even just to clear one container to another.
(f) Immediate report of missing drugs; wrong administration ă either route,

dose.
(g) Do not administer prescription via phone or verbally.
(h) Administer medication drawn yourself ă never ask another or accept a

drawn medication to be administered.
(i) Must have a valid license to administer drug or medicine.
(j) Check compatibility of multiple drugs if to be administered same site (IV) or

mixed in same syringe.

"
Labelling and Mixing of Drugs

Any mixture, liquid medication can only be mixed by a licensed person. This is
usually done by the pharmacist. In the current practice, the pharmacist will supply
medication to in-patients using the individual dosing system. When a physician
prescribes a medication, the healthcare providers will inform the pharmacist and
send in the prescription. If the organisation integrates it in their practice,
information of prescription will be delivered online, and this will minimise
medication error. Labelling of drugs must be done by an authorised person.
Healthcare providers are not allowed to perform any additional labelling or
transfer of drug from one container to another container.
SELF-CHECK 1.4
State some of the procedures for the safekeeping of drugs or medicine

and administration.
ACTIVITY 1.4
1. What are the current practices of administration of drugs classified

under DCA in your workplace?
2. List the drugs considered as controlled drugs in your organisation.
1.6 HEALTHCARE PROVIDERS’ ROLE IN

HEALTH EDUCATION OF MEDICATION
ADMINISTRATION
In this subtopic, you will learn on the healthcare providersÊ role in providing
health education for safe and effective medication administration. One of the core
functions of a healthcare provider in relation to pharmacology is medication
administration. In some advanced nations, this role has been taken over by the
clinical pharmacist. This is a very important and significant role with a high level
of responsibility expected from the healthcare providers.

"
An important aspect of the responsibility for the healthcare provider is observing

the crucial processes involved in medication administration, which has been
described as the „Rights‰ of medication administration. Currently there are 7 RÊs
commonly recorded, but some even mentioned 11 RÊs. The 11 rights of medication
administration are shown in Figure 1.3.
Figure 1.3: 11 rights (11 RÊs) of medication administration

"
All of the RÊs mentioned in Figure 1.3, if followed diligently, will minimise/
eliminate medication errors. Do remember that the first 8 RÊs is mandatory practice
in many organisations. Over the last 20 years, this procedure has seen
transformation changes in the processes and procedures, with the intent of
eliminating medication errors. Although the processes have been simplified for
patient safety as well as safe and efficient processes introduced in minimising or
eliminating medication errors, recent research shows many medication errors still
occur.
Medication errors have detrimental effects on lives and impacts directly on the
patient, family as well as medication administrators and organisation. The risks of
medication errors include the prospects of mortality and morbidity to clients that
will also have a direct impact on the family, stress and anxiety, longer hospital
stays and financial constraints. The medication administrators and organisation
also suffer from negative image, loss of integrity and may have to face litigation.
Education to patients to improve medication compliance involves the following:
(a) Patients must be educated on their medication, recognise their regular

medication, know the generic names, dose and expected outcome of the
medication.
(b) Teaching by giving handouts and use of audiovisual teaching aids on

medications (at a reading level and language the patient can understand).
(c) Providing contact information for health care providers whom the patient
should notify immediately in the event of adverse reactions.
(d) Education on proper storage of medication, particularly those that have

special requirements, such as be protected from light.
(e) Regular checking on time-expired medications.
(f) Avoid/never transfer medication from one container to another.
(g) Prevent overstocking of medications.

"
SELF-CHECK 1.5
1. What are the 11 rights of medication administration?
2. As a healthcare provider, how would you ensure that the

medication that you are administering is correct?
ACTIVITY 1.5
1. Explain your preparation on delivering health education on
medication to an elderly patient prior to his discharge from the
hospital.
2. Describe the common errors of medication administration.
Share your answers in the myINSPIRE online forum.
 Pharmacotherapeutics or pharmacotherapy describes the application of drugs

or therapeutic agents in order to prevent and cure disease or medical
conditions and provide treatment to alleviate the suffering of an individual.
 Pharmacokinetics is a term that denotes the study of the movement of drugs

within the body or the activities of the drugs once it enters the body until it is
discharged from the system.
 Pharmacodynamics is a term from two words; pharmaco, the root word,

meaning medicine, and dynamics which means the changes brought about by
the responses of the drugs to the body.
 The routes through which medications are commonly administered can be

divided into topical, enteral and parenteral routes.
 One way to classify drugs is according to their basis or origin such as drugs
from natural origin, chemical, chemical synthesis, animal origin and drugs
derived from microbial origin.
"

"
 Two common types of drug classifications are therapeutic and

pharmacological classification.
 Many drugs are not only identified by a single name, but by three names; the
chemical, generic and trade names.
 A prescription drug is a drug that requires a drug prescription form. A drug

prescription form is a list that contains the description of a single drug or
multiple drugs to be made available to the named person on the list.
 Drugs that can be bought without a prescription are called „over-the-counter

drugs‰. These drugs are commonly found in any household and considered as
non-poison drugs.
 In Malaysia, Act 366, Poisons Act (1952), revised in 1989 is referred to for all
matters pertaining to drugs. All pharmaceuticals in Malaysia are regulated by
Drug Control Authority (DCA) under the Control of Drugs and Cosmetics
Regulations 1984.
 An important aspect of the responsibility for the healthcare provider is

observing the crucial processes involved in medication administration, which
has been described as the „RightÊs‰ of medication administration.
 Patients must be educated on their medication, recognise their regular

medication, know the generic names, dose and expected outcome of the
medication.
Adverse drug reaction Pharmacology

Adverse event Pharmacotherapeutics
Medication error Pharmacotherapy
Over-the-counter drugs Prescription drugs"
Pharmacodynamics Side effects"
Pharmacokinetics Therapeutic index

"
Act 366 Poisons Act 1952 (Revised 1989). Laws of Malaysia. Retrieved from
http://www.pharmacy.gov.my/v2/sites/default/files/document-
upload/poisons-act-1952-act-366.pdf
Adams, M., Holland, L. N., & Urban, C. Q. (2014). Pharmacology for nurses:
A pathophysiologic approach (4th ed.). Upper Saddle River, NJ: Pearson.
Barber, P., Parkes, J., & Blundell, D. (2012). Further essentials of pharmacology for
nurses. Maidenhead, England: Open University Press/McGraw-Hill.
Clayton, B., & Willihnganz, M. (2012). Basic pharmacology for nurses (16th ed.).
St. Louis, MO: Elsevier.
Craig, G. P. (2012). Clinical calculations made easy: Solving problems using

dimensional analysis (6th ed.). New York, NY: Wolters Kluwer.
Kee, J. L., Hayes., E. R., & McCuistion, L. E. (2015). Pharmacology: A patient-

centred nursing process approach. St. Louis, MO: Wolters Kluwer.
Yeager, J. J., Burchum, J., & Rosenthal, L. (2015). Study guide for LehneÊs
pharmacology for nursing care (9th ed.). St. Louis, MO: Elsevier.

Topic
" " "
"
"
"
 Pharmacology
"
and Adverse
2
"
"
Effects of Drugs
"
"
"
"
"
"
" LEARNING OUTCOMES
"
" 1. Describe the assessment of patients related to drugs administration;
"
" 2. Discuss the importance of evaluating the effectiveness of drug
" administration;
" 3. List the five rights of drug administration that a nurse should
" practice in order to provide safe drug administration;
"
" 4. Describe some of the factors that contribute to medication errors;
" and
" 5. Discuss the adverse effects of drugs.
"
 INTRODUCTION
In this topic, we will discuss pharmacology and assessment of patient in relation
to drug administration. Drugs administration is essential to provide a holistic
approach and prevent medication errors. Healthcare providers need to apply the
knowledge of drug administration for patients from different age groups. The
same knowledge should be appreciated by the healthcare providers in specific
precautions for high alert medications in various body systems.

TOPIC 2 PHARMACOLOGY AND ADVERSE EFFECTS OF DRUGS  23
"
This topic will provide you with a better understanding on how healthcare
providers can contribute to safe drug administration, thus, healthcare providers
need to know how medication errors occur and the factors that contribute to them.
This topic will also enhance your understanding of the nature of medication errors
generally made by healthcare providers. Lastly, we will study the impact of
medication errors and adverse effects of drugs.
2.1 " ASSESSMENT OF PATIENTS RELATED TO

DRUG ADMINISTRATION"
How about assessment of patients related to drug administration? Health and
physical assessment are completed during the initial meeting between a healthcare
providers and patient. The initial history is tailored to the patientÊs clinical
condition.
The essential questions that need to be asked by healthcare providers are as

follows:
(a) History of allergies;
(b) Past medical history;
(c) Medication currently used and in the recent past;
(d) Personal and social history such as the use of alcohol, tobacco or caffeine;
(e) Health risks such as the use of recreational drugs or other illicit substances;
and
(f) Reproductive health questions such as the pregnancy status of women of

childbearing age.

24  TOPIC 2 PHARMACOLOGY AND ADVERSE EFFECTS OF DRUGS
"
The pertinent questions that may be asked during the initial health history that
will provide baseline data before medications are administered are shown in
Table 2.1.
Table 2.1: Health History Assessment Questions Pertinent to Drug Administration
Health History
Component Pertinent Questions
Areas
Chief complaint  How do you feel?

 Are you having any pain?
 Are you experiencing other symptoms (especially pertinent to
side effects of medication are nausea, vomiting, headache,
itching, dizziness and shortness of breath)?
Allergies  Are you allergic to any medication?

 Are you allergic to any foods, environmental substances?
 What specifically happens when you experience an allergy?
Past medical  Do you have a history of diabetes, heart or vascular conditions,

history respiratory conditions and neurological conditions?
 Do you have any dermatologic conditions?
 How have these been treated in the past? Currently?
Family history  Has anyone in your family experienced difficulties with any
medications?
 Does anyone in your family have any significant medical
problems?
Drug history  What prescription medications are you currently taking (e.g.
list drug name, dosage and frequency)?
 What non-prescription/OTC medications are you taking?
 Have you ever experienced any side effects or unusual
symptoms with medications?
 What do you know, or have been taught, about these
medications?
 Do you use any herbal or homeopathic remedies? Any
nutritional substances or vitamins?
" "
"
Health  Identify all the healthcare providers you have seen for health
management issues
 When was the last time you saw a healthcare provider and for
what reason?
 What is your normal diet?
 Do you have any trouble sleeping?
Reproductive  Is there any possibility that you are pregnant?

history
 Are you breastfeeding?
Personalăsocial  Do you smoke?

history
 Do you consume alcohol? If yes, what is the usual amount of
alcohol that you consume in a week?
 What is your normal caffeine intake?
 Do you have any religious or cultural beliefs or practices
concerning medications?
 What is you occupation? What hours do you work?
 Do you have any concerns regarding insurance or the ability to
afford medications?
Health risk  Do you have any history of depression or other mental illness?
history
 Do you use any recreational drugs or illicit substances?
Source: Adams, Holland and Bostwick (2008)
The health history should be tailored to the patientÊs condition. Also, the
healthcare providers have to be very careful as some questions may not be
appropriate during initial assessment. Keep in mind that what is not being
disclosed by the patient. The healthcare provider must use their observation skills
during the history to gather critical data from nonverbal communication signals.
The physical assessment is completed to gather objective data on the patientÊs

condition. Vital signs, height and weight, a head-to-toe physical assessment and
lab specimens have to be obtained. These values provide the baseline data to
compare with future assessment.

"
Baseline electrolyte values are important parameters to obtain because many

medications affect electrolyte balance. Renal and hepatic function tests are
essential for many patients, particularly older adults and those who are critically
ill.
The healthcare providers have to conduct ongoing assessment once

pharmacotherapy is initiated to determine the side effects of the medications. The
assessment should focus on determining whether the patient is experiencing the
expected therapeutic benefits from the medications. For example, if the drug is
given for symptoms of pain, has the pain subsided? Assessment during
pharmacotherapy also focuses on any side or adverse effects and often these effects
are manifested in dermatologic, cardiovascular, gastrointestinal, or neurologic
symptoms. Finally, it is necessary to conduct an assessment of the ability of the
patient to assume responsibility for self-administration of medication.
SELF-CHECK 2.1
What are some of the pertinent questions that a healthcare provider can
ask in relation to a patientÊs past medical history and personal-social
history?
2.1.1 Assessment of Patient Problems

Assessment data are used to develop a list of medical problems, that address the
patientÊs responses to health and life processes to set goals and plan care. The focus
should be on the patientÊs problem and are prioritised by importance to the
patientÊs clinical condition.
Drug administration is the same as diagnoses written for other patient condition-
specific responses. They may address actual problems, such as the treatment of
pain or focus on potential problems such as a risk for fluid volume deficits.
Table 2.2 lists the common patient problems in drug administration.

"
Table 2.2: Common Patient Problems in Drug Administration
Common Patient Problems in Drug Administration

 Activity intolerance  Liver function, impaired, risk for
 Airway clearance, ineffective  Mobility, physical, impaired
 Anxiety  Nausea
 Aspiration, risk for  Noncompliance
 Breathing pattern, ineffective  Nutrition, imbalanced
 Cardiac output, decreased  Oral mucous membrane, impaired
 Comfort, enhanced, readiness for  Pain
 Communication, impaired verbal  Poisoning, risk for
 Constipation  Self-care deficit
 Coping, ineffective  Sensory perception, disturbed
 Diarrhoea  Sexual dysfunction
 Falls, risk for  Skin integrity, impaired
 Fatigue  Sleep pattern, disturbed
 Fluid volume, deficient  Stress, overload
 Fluid volume, excess  Suicide, risk for
 Gas exchange, impaired  Swallowing, impaired
 Hyperthermia  Thought processes, disturbed
 Hypothermia  Tissue perfusion, ineffective
 Infection, risk for  Incontinence
 Injury, risk for  Urinary retention
 Knowledge, deficient
Source: North American Nursing Diagnosis Association (2007)
"

"
2.1.2 Setting Goals and Outcomes for Drug

Administration
Before administering and monitoring the effects of medication, the healthcare
provider should establish clear, realistic goals and outcomes so that the planned
interventions ensure safe and effective use of these agents. Goals will focus on
what the patients should be able to achieve and do and must be based on the
patientÊs problem established from the assessment data.
Outcomes for drug administration provide the specific, measurable criteria that
will be used to evaluate the degree to which the goal was met. In this context, both
goals and outcomes are focused on what the patient will achieve or do realistically
and are discussed between the patients and caregivers.
Priorities are established based on the assessment data and patientÊs problem. Safe
and effective administration of the medications is the overall goal of any care plan.
Goals may be focused for the short-term or long term. In acute care or in an
ambulatory setting, short-term goals are most appropriate. In a rehabilitation
setting, long-term goals may be more commonly identified.
ACTIVITY 2.1
A patient with a thrombus in the his/her lower extremity has been placed
on anticoagulant therapy. Identify the short-term goal and the long-term
goal for this patient. What would be the expected outcomes for this
patient? Please discuss your answers in the myINSPIRE online forum.
2.1.3 Key Interventions for Drug Administration

We are coming to another important part in drug administration, namely
intervention. The healthcare provider must perform primary intervention, which
is monitoring the effects of the drug. The healthcare provider requires thorough
knowledge of the actions of each medication and should monitor for the identified
therapeutic effect.
Monitoring may require a reassessment of the patientÊs physical condition, vital

signs, body weight, lab values, and/or serum drug levels. The patientÊs statement
about pain relief, as well as objective data, such as blood pressure will be used to
monitor the therapeutic outcomes of pharmacotherapy.

"
The nurse also monitors for any side and adverse effects and attempts to prevent
or limit these effects when possible. Some side effects can be managed by the
healthcare provider independently, whereas, others may require collaboration
with the doctor to alleviate the patientÊs symptoms. For example, for a patient
exhibiting nausea and vomiting after receiving a narcotic pain reliever, the
healthcare provider may need to provide comfort to the patient by giving small
frequent meals, sips of carbonated drinks and frequent changes of linen if they are
soiled. In addition, the physician may need to prescribe an antiemetic drug to
control the side effects of intense nausea.
During the intervention phase, the appropriate administration of the medication,

as well as the effects need to be observed and documented correctly.
An important intervention will be on teaching the client. Knowledge deficit and

noncompliance are directly related to the type and quality of medication education
that the patient receives. Teaching is aimed at providing the patient with the
information to ensure the fundamental goals of pharmacotherapy such as safe
administrations and the best therapeutic outcomes will be achieved.
ACTIVITY 2.2
Identify the important areas of teaching for a patient receiving

medications and the important questions and observations that you will
ask. Discuss and do a presentation on this during tutorial.
2.1.4 Evaluating the Effects of Drug Administration

The final step of drug the administration process is evaluation. Evaluation
considers the effectiveness of the interventions by the healthcare provider in
meeting established goals and outcomes. When evaluating the effectiveness of
drug administration, the healthcare provider assesses for optimum therapeutic
effects and minimal occurrence of side or adverse effects. They also evaluate the
effectiveness of teaching provided and notes areas where further drug compliance
education is needed.
Evaluation is not the end of the process but the beginning of another cycle as the
healthcare provider continues to work to ensure safe and effective medication use
and active involvement of the patient. Evaluation is a checkpoint where the
healthcare provider considers the overall goals of safe and effective administration
of medications and takes the steps to ensure success.

"
SELF-CHECK 2.2
Briefly discuss the importance of evaluating the effectiveness of drug

administration.
2.2 PHARMACOTHERAPY ACROSS THE

LIFESPAN
As a healthcare provider, you must understand normal growth and
developmental patterns that occur throughout the lifespan in order to provide
optimum care. As we know, the development of a person is a complex process that
links various components that is, the biophysical with the psychosocial, ethno-
cultural, and spiritual components to make each individual a unique human being.
The whole-person view is essential to holistic care, thus, the very nature of
pharmacology requires the healthcare provider to consider the individuality of
each client/patient and the specifics of age, growth and development in relation
to pharmacokinetics and pharmacodynamics. "
2.2.1 Drug Administration during Childhood

As a child develops, physical growth and physiological changes mandate
adjustments in the administration of medications. Although children may receive
similar drugs via routes similar to those in adults, the management for children is
very different from that of adults.
The healthcare provider has to consider various factors regarding drug

administration during childhood. The factors include the following:
(a) Physiological variations;
(b) Maturity of body systems; and
(c) Greater fluid distribution in children.
These factors can exaggerate or diminish the effectiveness of paediatric drug

therapy. Drug dosages are vastly different in children. Almost all drug dosages are
calculated on the basis of a childÊs weight in kilograms.

"
ACTIVITY 2.3
1. Do some research on the pharmacotherapy of infants, toddlers,
preschoolers and school-aged children and adolescents. Discuss the
role and responsibilities of the healthcare provider on the
assessment and the administration of the medications to those
groups stated earlier.
2. Imagine a healthcare provider is preparing to give an injection to

an infant. Where do you think the preferred site for injections for
newborns and infants will be?
2.2.2 Drug Administration during Adulthood

Now, let us look at the drug administration during adulthood. As a healthcare
provider, we have to consider the health of our client. When considering adult
health, it is customary to divide the period of life in three stages as shown in
Figure 2.1.
Figure 2.1: Three stages of adulthood
Within each of these divisions are similar biophysical, psychosocial, and spiritual
characteristics that affect nursing and pharmacotherapy. Firstly, we will look into
the pharmacotherapy of young and middle-aged adults and then of older adults.
(a) Pharmacotherapy of Young and Middle-aged Adults

Generally, the health status of younger adults is good; absorption, metabolic,
and excretion mechanisms are at their peaks. Usually, there is minimal need
for prescription of drugs unless the adult client has chronic diseases such as
diabetes or immune-related conditions. Medication compliance among adult
clients is positive within this age range. The physical status of the middle-
aged adult is at par with that of the young adult until about the age of 45.
During this period of life, numerous transitions occur that often result in
excessive stress.

"
The middle-aged adults are sometimes referred to as the „sandwich‰

generation, because they are often caring for their aging parents as well as
their children and grandchildren. Due to the pressure of work and family,
middle-aged adults often take medications to control health alterations that
could be best treated with positive life-style modifications. Therefore, it is
important in providing care to the client at this age group, to emphasise the
importance on overall health of lifestyle choices, such as limiting lipid intake,
maintaining optimum weight and regular exercise.
Quite commonly, several health impairments related to cardiovascular

disease, hypertension, obesity, arthritis, cancer, and anxiety begin to surface
in middle-aged adults. The majority of them will be on medical drugs to treat
hypertension, hyperlipidaemia, digestive disorders, erectile dysfunction,
and arthritis.
(b) Pharmacotherapy of Older Adults

The quality of life and the ability of effective treatment of many chronic
diseases have contributed to increased longevity. As a person ages, many
physiological changes occur. The age-related changes in older adults
influence the individualÊs response to drugs, which may alter both the
therapeutic and adverse effects, and create special needs and risks.
Normally in older adults, the functional ability of all major organ systems
progressively declines. Therefore, all phases of pharmacokinetics are affected
and appropriate adjustments in therapy need to be implemented. Normal
physiological changes that affect pharmacotherapy of the older adults can
influence the function of absorption, distribution, metabolism and excretion
of the drug therapy.
ACTIVITY 2.4
Discuss the normal physiological changes that affect pharmacotherapy

during the phases of absorption, distribution, metabolism and excretion.
Identify the adverse effects of medications on the elderly.
SELF-CHECK 2.3
1. State the three stages of adulthood.
2. What are the health problems generally faced by middle aged

adults?

"
2.3 PRINCIPLES OF DRUG ADMINISTRATION

To provide safe drug administration, the nurse should practice the „rights‰ of drug
administration. They are as shown in Figure 2.2.
Figure 2.2: The „rights‰ of drug administration
Let us now explore further the five „rights‰ of drug administration:
(a) The Right Client

The identity of the right client needs to be confirmed by checking the
wristband and by checking a second piece of identification. This could be a
picture on the chart, or a case number that is both on his chart and wristband.
This must be done before any medication is administrated.
(b) The Right Drug

The right drug means that the client receives the drug that was prescribed by
a physician. The use of computerised systems to record medications has
helped to decrease medication errors, because healthcare providers are not
trying to read written forms of the prescriptions. Doctors can electronically
add a new medication order to a patientÊs chart from any location. If there is
a phone order or verbal order, it must be co-signed by the prescribing
physician within 24 hours.
The components of a drug order are as follows:
(i) Date and time the order is written;
(ii) Drug name (generic is preferred);
(iii) Drug dosage;

"
(iv) Route of administration;
(v) Frequency and duration of administration (for example, for seven days,
three doses a day);
(vi) Any special instructions for withholding or adjusting dosage based on

nursing assessment, drug effectiveness, or laboratory results;
(vii) Physician or other health care providerÊs signature or name of

telephone order (TO) or verbal order (VO); and
(viii) Signature of licensed practitioner taking TO or VO.
If any of these components are missing, the entire order is incomplete and
the medication should not be given. To avoid error, the healthcare provider
must check the label on the medication container against the order for the
medication three different times:
(i) At the time of contact with medication container;
(ii) Before pouring the drug out for dispensing; and
(iii) After pouring out the drug.
Drugs given for the first dose, one-time or PRN medication should always
be checked against the original order. Beware of medications that sound
alike, and read the labels carefully. The medical implication includes the
following:
(i) Check that medication order is complete and legible;
(ii) Know why the client is receiving the medication;
(iii) Check the drug label three times before administration; and
(iv) Know the start date that the drug was ordered and the ending date.
The following are the four categories of drug orders:
(i) Standing orders;
(ii) One-time (single dose);
(iii) PRN (when needed); and
(iv) STAT (at once).

"
(c) The Right Dose

The right dose is the dose prescribed for a particular client. The healthcare
provider is responsible for questioning any dose that looks too high or too
low. Always consult a peer or pharmacist if the dosage appears incorrect.
Beware of paediatric doses that are based on body weight. Weights can
change daily so regular assessment of dosages is crucial.
The medical implications include the following:
(i) Calculate the drug dose correctly. For some medications, two
healthcare providers are needed to sign off on a new order such as
heparin and insulin.
(ii) Check the hospital formulary, drug package insert, or other drug
references for recommended range of specific drug doses.
(d) The Right Time

The right time is the time at which the prescribed dose should be
administered. The healthcare provider`s implications include the following:
(i) Administer drugs at the specified times. Drugs maybe given 0.5 hour
before or after the time prescribed if the administration interval is
>2 hours. Refer to the hospital drug policy when in doubt.
(ii) Administer drugs that are affected by foods, before or after meals (for
example, tetracycline).
(iii) Administer drugs such as aspirin or potassium that can irritate the
stomach (gastric mucosa) with food.
(iv) The drug administration schedule can sometimes be flexible in order to

accommodate the clientÊs activities for the day or preferences.
(v) It is the healthcare providerÊs responsibility to be aware of tests or

procedures that are taking place, which may affect the medication
administration (for example, fasting blood tests and endoscopy).
(vi) Check the expiration date on medications and return to pharmacy if

expired.
(vii) Antibiotics need to be given evenly over 24 hours.

"
(e) The Right Route

The right route is necessary for adequate or appropriate absorption. The
following are the healthcare provider`s implications with regard to route:
(i) Assess clients ability to swallow before administering per oral/p.o.
(ii) Do not crush or mix medications into other substances before

consultation with the pharmacy. Do not mix medications into
sweetened juices for kids or add to formula for babies. Follow all
medical administration guidelines for that drug.
(iii) Use aseptic technique when administering drugs. Use sterile technique
when administering parenteral medications.
(iv) Administer drugs to appropriate sites.
(v) Stay with client until per oral/p.o. medications have been swallowed.
(vi) If it is necessary to combine a medication with another substance,

explain to the client.
Experience indicates that five additional rights that are essential to professional
nursing practice. Figure 2.3 shows these five additional rights.
Figure 2.3: The five additional rights essential to professional nursing practice
ACTIVITY 2.5
Discuss in a group on the appropriate action that should be taken when

a healthcare provider has administered medication to the wrong client.

"
SELF-CHECK 2.4
1. List the five rights of drug administration that a healthcare provider

should practice in order to provide safe drug administration.
Briefly describe any two of the rights.
2. What are the five additional rights that are essential to professional
nursing practice?
2.4 MEDICATION ERRORS AND RISK

MANAGEMENT
In the clinical practice, healthcare providers need to be sensitive to the complexities
of risk reduction and medication errors. The healthcare provider is responsible for
ensuring the clientÊs safety by striving for 100 per cent accuracy when
administering medications. Healthcare providers must value the proficiency and
the accuracy in giving the medications to clients. They need to adhere to the ethical
principle of non-maleficence and beneficence as an obligation to seek interventions
that are beneficial for the patients.
So, let us look at the definition of medication error. The National Coordinating
Council for Medication Error Reporting and Prevention (NCC MERP) defines
medication error as follows:"
A medication error is any preventable event that may cause or lead to

inappropriate medication use or patient harm while the medication is in
control of the healthcare professional, client or consumer. Such events may be
related to professional practice, health care products, procedures, and
systems, including prescribing, order communication, product labelling,
packaging, and nomenclature, compounding, dispensing, distribution,
administration, education, monitoring and use (NCC MERP, 2015).
"
Medication errors can be broadly defined as any error in the prescribing,
dispensing, or administration of a drug, irrespective of whether such errors lead
to adverse consequences or not. Medication errors are the single most important
preventable cause of patient harm.

"
2.4.1 What are the Factors Contributing to

Medication Errors?
Proper medication administration involves a partnership between the healthcare
provider and the clients/patients. The relationship is dependent on the
competence of the healthcare provider as well as the patientÊs compliance with
drug therapy. This dual responsibility provides a simple, useful way to
conceptualise medication errors as resulting from healthcare error or patient error.
The purpose of classifying and studying these errors is not to assign individual
blame but rather to prevent future errors.
According to Adams, Hollands and Bostwick (2008), the following are the factors
contributing to medication errors by healthcare providers:
(a) Omitting one of the rights of drug administration ă common errors include
giving an incorrect dose, not giving an ordered dose and giving an
unordered dose.
(b) Failing to perform an agency check. Both pharmacists and nurses must
collaborate on checking the accuracy and appropriateness of drug orders
prior to administering drugs to clients/patients.
(c) Failing to account for client/patient variables such as age, body size and
renal or hepatic function. Healthcare providers should always review recent
laboratory data and other information in the chart before administering
medications, especially those drugs that have a narrow margin of safety.
(d) Giving medications based on verbal orders or phone orders, which may be
misinterpreted or go undocumented. Healthcare providers should remind
the prescribing healthcare practitioner that medication orders must be in
writing before the drug can be administered.
(e) Giving medications based on an incomplete order or an illegible order, when

the nurse is unsure of the correct drug, dosage, or administration method.
Incomplete orders should be clarified with the healthcare provider before
medication is administered. The following recommendations on the written
orders should be followed closely (NCC MERP, 2014):
(i) A brief notation of purpose (for example, for pain).
(ii) Metric system measurements except for therapies that use standard
units such as insulin or vitamins.

"
(iii) ClientÊs age and, when appropriate, weight.
(iv) Drug name, exact metric weight or concentration and dosage form.
(v) A leading zero preceding a decimal number less than one (for example,
0.5mg instead of .5mg).
(vi) Avoidance of abbreviations for drug names (for example, MOM,

HCTZ) and Latin directions for use.
(f) It was found that practicing under stressful work conditions can cause
medication errors. Studies have correlated an increased number of errors
with stress level of nurses. Studies have also indicated that the rate of
medication errors may increase when individual nurses are assigned to
clients who are most acutely ill.
Clients/patients, or their home caregivers, may also contribute to medication

errors by making the following mistakes:
(a) Taking drugs prescribed by several practitioners without informing those

healthcare providers about all prescribed medications.
(b) Getting their prescriptions filled at more than one pharmacy.
(c) Not filling or refilling their prescriptions.
(d) Taking medication incorrectly.
(e) Taking medications that may have been left over from previous illness or
prescribed for something else.
SELF-CHECK 2.5
1. Describe some of the factors that contribute to medication errors.
2. What are the elements that should be included when giving written
orders?
"

"
2.4.2 The Impact of Medication Errors

Medication errors are the most common cause of morbidity and preventable death
within hospitals. When medication errors occur, the effect can be emotionally
devastating for the nurse. It extends beyond the particular nurse and client
involved.
Medication errors can cause the following:
(a) Increase the patientÊs length of stay;
(b) Increase the costs and time that a patient is separated from his or her family;
(c) The nurse will suffer self-doubt and embarrassment;
(d) The nursing unit may develop a poor reputation;
(e) The reputation of facility may suffer and maybe perceived as unsafe; and
(f) The administrative personnel may also be penalised because of errors within
their department or the hospital as a whole.
The goal of every healthcare organisation should be to improve medication

administration systems to prevent harm to clients/patients due to medication
errors. All errors should be investigated with the goal of identifying ways to
improve the medication administration process to prevent future errors.
It is always the healthcare providerÊs legal and ethical responsibility to report all
occurrences of medication errors. This is because when a healthcare provider
commits or observes an error, the effects can be lasting and widespread. In severe
cases, adverse reactions caused by medication errors may require lifesaving
interventions for the patient. After such an incident, the patient may require close
supervision and additional medical treatments.
SELF-CHECK 2.6
What is the impact of medication errors? Explain.

"
2.4.3 Strategies for Reducing Medication Errors

What can the healthcare provider do to avoid medication errors and promote safe
administration? The healthcare provider can begin by adhering to the steps in the
following four stages (Adams, Holland & Bostwick, 2008):
(a) Assessment
The healthcare provider will ask the patient about allergies to food or
medications, current health concerns, and the use of over-the-counter (OTC)
medications and herbal supplements. Ensure the patient is receiving the right
dose, at the right time and by the right route. Assess renal and liver functions,
and determine if other body systems are impaired and could affect
pharmacotherapy. Identify areas of needed patient education with regard to
medications.
(b) Planning
The healthcare provider will minimise factors that contribute to medication
errors. Avoid using abbreviations that can be misunderstood, question
unclear orders, do not accept verbal orders, and follow specific facility
policies and procedures related to medication administration. Have the
patient restate dosing directions, including the correct dose of medication
and the right time to take it. Ask the client to demonstrate an understanding
of the goals of therapy.
(c) Implementation
The healthcare provider should be aware of potential distractions during
medication administration and remove these distractions. When the nurse is
engaged in a medication-related task, focus entirely on the task. Practice the
following rights of medication administration:
(i) Right client/patient;
(ii) Right time and frequency of administration;
(iii) Right dose;
(iv) Right route of administration; and
(v) Right drug.

"
As a healthcare provider, we have to keep the following steps in mind as

well:
(i) Positively verify the identity of each client before administering the
medication according to facility policy and procedures.
(ii) Use the correct procedures and techniques for all routes of
administration. Use sterile materials and aseptic techniques when
administering parenteral or eye medication.
(iii) Calculate medication doses correctly and measure drugs carefully.

Some medications, such as heparin, have a narrow safety margin for
producing serious adverse effects. When giving these medications, ask
a colleague or a pharmacist to check the calculations to make certain
the dosage is correct. Always double-check paediatric calculations
prior to administration.
(iv) Open medication immediately prior to administering the medication

and in the presence of the patient.
(v) Record the medication immediately after administration.
(vi) Always confirm that the client has swallowed the medication. Never
leave the medication at the bedside unless there is a specific order that
medications maybe left there.
(vii) Be alert for long acting oral dosage forms with indicators such as LA,
XL and XR. These tablets or capsules must remain intact for the
extended-release feature to remain effective. Instruct the patient not to
crush, chew, or break the medication in half, because it can cause an
overdose.
(d) Evaluation
The healthcare provider has to assess the client for expected outcomes and
determine if any adverse effects have occurred.
SELF-CHECK 2.7
Explain the steps that a healthcare provider should follow to reduce

medication errors in the implementation stage.

"
ACTIVITY 2.6
Discuss in a group, the special considerations on age-related issues in

drug administration among the paediatric and the elderly.
2.4.4 Providing Patient Education for Medication

Usage
There are several effective strategies for avoiding medication errors. It is important
to educate the client by providing written age-appropriate handouts, audiovisual
teaching aids about medication, and contact information about whom to notify in
the event of an adverse reaction.
There are several aspects that the healthcare provider could teach the clients/
patients to do, such as the following:
(a) Know the names of all medication they are taking, the uses, when they
should be taken and the doses.
(b) Know what side effects need to be reported immediately.
(c) Read the label prior to each drug administration and use the medication
device that comes with liquid medications rather than household measuring
spoons.
(d) Carry a list of all medications, including OTC drugs, as well as herbal and
dietary supplements that are being taken. If possible, use one pharmacy for
all prescriptions.
(e) Ask questions. Healthcare providers must be partners to maintain safe

medication principles.
SELF-CHECK 2.8
What can a healthcare provider teach patients in relation to appropriate

medication usage?

"
2.4.5 Risk Management

Most of the larger healthcare agencies often have risk-management departments
to examine risks and minimise the number of medication errors. Risk-management
personnel investigate incidents of medication errors, track data, identify problems
and provide recommendations for improvement. In this aspect, the nurse has to
collaborate with the risk-management committees to seek means of reducing
medication errors by modifying policies and procedures within the institution.
There are policies and procedures that are being carried out in a healthcare
institution including:
(a) Correctly storing medication (to protect damage from light and temperature
exposure);
(b) Reading the drug label to avoid using time-expired medications;
(c) Avoiding the transfer of doses from one container to another; and
(d) Avoiding overstocking of medications.
Facilities use risk-management department and agencies policies and procedures

to decrease the incidents of medication errors. Automated, computerised, locked
cabinets for medication storage are a means of safekeeping of medications and
keeping track of inventory at the unit/ward level.
ACTIVITY 2.7
In a group, discuss the strategies taken by healthcare providers to reduce

medication errors. Identify the relevant policies and procedures that
apply in your hospital. You are to present your answers during the next
tutorial.
"

"
2.5 ADVERSE EFFECT OF DRUGS

Before ending this topic, let us have a look at the adverse effects of drugs, as all
drugs are potentially dangerous. Even though chemicals are carefully screened
and tested before they are released as drugs. Drugs are chemicals and the human
body operates by a vast series of chemical reactions.
Adverse effects are undesired effects that maybe unpleasant or dangerous. The
healthcare providers must be constantly alert to signs of drug reactions of various
types.
Adverse effects of drugs can be divided into three; primary actions, secondary
action and hypersensitivity.
2.5.1 Primary Actions

The most common occurrence in drug therapy. In this case, patients will suffer
from the effects of drug overdose. For example, an anticoagulant may act so
effectively that the patient may experience excessive and spontaneous bleeding.
This adverse effect can be avoided by monitoring the patient carefully and
adjusting the prescribed dose to fit that particular patient`s needs.
2.5.2 Secondary Actions

Drugs can produce a wide variety of effects in addition to the desired
pharmacological effect. The drug dose needs to be adjusted so that the desired
effect is achieved without producing undesired secondary reactions. For example,
antihistamine is very effective in drying up secretions and improve breathing but
can also cause drowsiness.
2.5.3 Hypersensitivity
Some patients are excessively responsive to the primary or the secondary effects
of drugs. For example, many drugs are excreted through the kidneys; a patient
who has kidney problems may not be able to excrete the drug and may accumulate
the drug in the body, causing toxic effects.
"

"
2.6 TOXICITY
Drugs can act directly to cause many types of adverse effects to various tissues,
structure and organs. For organ toxicity, let us discuss liver and renal injuries in a
little more depth.
2.6.1 Liver Injury

Oral drugs are absorbed and passed directly into the liver in the first-pass effect.
Most drugs are metabolised in the liver, so any metabolites that are irritating or
toxic will also affect liver integrity.
Healthcare providers need to assess patients with liver injury. The symptoms may
include fever, malaise, nausea, vomiting and jaundice. The best intervention is to
discontinue the drugs and notify the physician. Offer supportive measures such as
small frequent meals, skin care and a cool environment.
2.6.2 Renal Injury

Some drug molecules get plugged into the capillary of the glomerulus in the
kidney, causing acute inflammation and severe renal problems. Gentamycin a
potent antibiotic, is frequently associated with renal toxicity.
The clinical investigations will show that there is elevation of blood urea,
creatinine concentration, decreased hemotocrit, electrolyte imbalance, irritability
and skin rash may be present. For this situation, the healthcare provider needs to
notify the physician, impose diet and fluid restriction, correct the electrolyte levels
and provide suitable skin care.
"
SELF-CHECK 2.9
What are the procedures that can be carried out in a healthcare institution
as risk management strategies?
"

"
ACTIVITY 2.8
30 A patient taking an antidiabetic drug has his morning dose and then
does not have a chance to eat for several hours. Discuss the adverse
effects that might be expected from this situation. What would be
your advice to the patient?"
2. You may find more toxicity aspects in Pharmacology textbooks.

In groups, browse the website or visit OUM digital library. Then
share your findings in the myINSPIRE online forum.
 When considering adult health, it is customary to divide this period of life in

three stages; young adulthood, middle adulthood and older adulthood.
 Generally, the health status of younger adults is good; absorption, metabolic,

and excretion mechanisms are at their peaks. Usually, there is minimal need
for prescription of drugs unless the adult client has chronic diseases such as
diabetes or immune-related conditions.
 In older adults, the functional ability of all major organ systems progressively
declines. Normal physiological changes that affect pharmacotherapy of the
older adults can influence the function of absorption, distribution, metabolism
and excretion of the drug therapy.
 To provide safe drug administration, the healthcare provider should practice

the rights of drug administration; the right client, right drug, right dose, right
time and right route.
 Experience indicates that five additional rights are essential to professional

nursing practice, namely, the right assessment, right documentation, clientÊs
right to education, right evaluation and clientÊs right to refuse.
 A medication error is any preventable event that may cause or lead to

inappropriate medication use or patient harm while medication is in the
control of the healthcare professional, client or consumer.

"
 Medication errors are the most common cause of morbidity and preventable
death within hospitals. When medication errors occur, the effect can be
emotionally devastating for the healthcare providers.
 Healthcare providers can avoid medication errors and promote safe

administration by adhering to four main steps; assessment, planning,
implementation and evaluation.
 Adverse drug effects can range from allergic reaction to tissue or organ
damage. The healthcare provider involved in drug administration, needs to
assess such situations for potential adverse effects and intervene appropriately
to minimise those effects.
 It is important that a healthcare provider educate the client by providing

written age-appropriate hand-outs, audiovisual teaching aids about
medication, and contact information about whom to notify in the event of an
adverse reaction.
 Most of the larger healthcare agencies often have risk-management

departments to examine risks and minimise the number of medication errors.
Automated, computerised, locked cabinets for medication storage are a means
of safekeeping of medications and keeping track of inventory at the unit/ward
level.
Adulthood Middle adulthood

Adverse effects Older adulthood
Childhood Risk management
Drug administration Young adulthood
"

"
Adams, M. P., Hollands, L. N., & Bostwick, P. M. (2008). Pharmacology for nurses:
A pathophysiologic approach (2nd ed.). Upper Saddle River, NJ: Pearson/
Prentice Hall.
Livingstone/Elsevier.
Hale, T. W. (2004). Pharmacology review: Drug therapy and breastfeeding:

Pharmacokinetics, risk factors, and effects on milk production. NeoReviews,
5(4), 164ă172.
Jones, J. S., Fitzpatrick, J. J., & Rogers, V. L. (2012). Psychiatric-mental health

nursing: An interpersonal approach. New York, NY: Springer.
Karch, A. M. (2013). Focus on nursing pharmacology (6th ed.). Philadelphia:

National Coordinating Council for Medication Error Reporting and

Prevention (NCC MERP). (2014). Recommendations to enhance
accuracy of prescription/medication order writing. Retrieved from http://
www.nccmerp.org/recommendations-enhance-accuracy-prescription-writing
National Coordinating Council for Medication Error Reporting and Prevention

(NCC MERP). (2015). What is a medication error? Retrieved from http://
www.nccmerp.org/about-medication-errors
North American Nursing Diagnosis Association (NANDA). (2007). NANDA-I

nursing diagnoses: Definitions and classification, 2007ă2008. Philadelphia,
PA: NANDA International.

Topic
" " "
"
"  Pharmacotherapy
"
" for Conditions
3
"
"
"
"
of the
"
"
"
Cardiovascular
"
" System
"
"
" LEARNING OUTCOMES
"
" 1. Explain the specific precautions for frequent medications used in
" management of common cardiovascular system disorders;
"
" 2. Describe the common pharmacological therapy for acute heart
" failure and chronic heart failure;
" 3. List the three classes of the anti-arrhythmias agents; and
"
" 4. Explain the functions of dopamine used for treating severe
" hypotension and shock.
"
 INTRODUCTION
In Malaysia, coronary heart disease is the foremost cause of mortality in terms of
health-related problems (Ministry of Health, 2012). Separately, World Health
Organization (WHO) reported that the total number of deaths in Malaysia
resulting from coronary heart diseases was at 22,701, which constituted to
approximately 22.18 per cent of the total death in Malaysia (as cited in The Star
Online, 2015). Coronary artery disease is considered as a disease condition of the
modern age.

TOPIC 3 PHARMACOTHERAPY FOR CONDITIONS OF THE CARDIOVASCULAR  51
SYSTEM
"
Back in the 1960s, the death toll in Malaysia was mainly due to communicable
diseases such as tuberculosis, malaria, typhoid and cholera. This is due to the fact
that our country was then in a developing phase, thus the preventive and
promotive healthcare services were insufficient to meet the needs of the
population (Yayasan Jantung Malaysia, 2015). Today, the progress in healthcare
services has resulted in great reduction of mortality rates from communicable
diseases. Consequently, non-communicable diseases have taken the lead in
mortality and morbidity. Modern lifestyle behaviours have greatly contributed to
this new trend.
3.1 SPECIFIC PRECAUTIONS FOR FREQUENT

MEDICATIONS USED IN COMMON
CARDIOVASCULAR SYSTEM DISORDERS
Patients with heart diseases are often prescribed with multiple combinations of
drugs to stabilise their disease. The following are some of the pertinent precautions
relevant to the medications used for heart diseases:
(a) Diuretics
Diuretics are generally used to increase urine flow by blocking sodium and
water reabsorption in the kidneys. Such actions help to reduce elevated
blood pressure and also decrease excess water retention in the body known
as oedema. Examples of groups of diuretic drugs include the thiazides and
thiazide-like diuretics, the loop diuretics, osmotic diuretics, carbonic
anhydrase inhibitors and the potassium-sparing diuretics.
We must exercise caution when administering diuretics to patients with

impaired liver or kidney function. They should always be observed for signs
of fluid and electrolyte imbalance. This is also similar to patients who suffer
from diabetes. On the other hand, diuretics will cause acute toxic reactions
in patients on digitalis glycosides or non-depolarising muscle relaxants by
depleting serum potassium. Therefore, potassium supplements will be given
in these cases.
(b) Morphine Sulphate

Morphine has effective narcotic analgesic properties. It is used to relieve
severe pain due to acute myocardial infarction, cancers, suppression of
cough and occasionally in cases of difficulty in breathing due to pulmonary
oedema. Caution must be exercised when morphine is used for patients with
chronic respiratory diseases as it will cause respiratory distress. Other
complications of morphine use include orthostatic hypotension, retention of
urine, constipation and miosis.

52  TOPIC 3 PHARMACOTHERAPY FOR CONDITIONS OF THE CARDIOVASCULAR
SYSTEM
"
(c) Sodium Nitroprusside

Sodium Nitroprusside is administered intravascularly to reduce arterial high
blood pressure in hypertensive emergencies. The drug has immediate
vasodilation effects on the arteries and veins and the vasodilatory effects
stops as soon as the drug is discontinued. The following are several
implications during the administration of this drug:
(i) Firstly, continuous and precise blood pressure monitoring is vital

during administration of sodium nitroprusside.
(ii) Secondly, the IV infusion pack with sodium nitroprusside has to be

wrapped in an aluminium foil or similar opaque materials as exposure
to light rapidly degrades the potency of the drug action.
(iii) Thirdly, an infusion of sodium nitroprusside should not be continued

beyond three days due to the danger of cyanide poisoning. In patients
with renal and hepatic impairment, infusion should be for shorter
periods. Patients on sodium nitroprusside should also be monitored for
signs of metabolic acidosis, dizziness, nausea and acute hypotension.
(d) ACE Inhibitors

Angiotensin Converting Enzyme (ACE) inhibitors are mainly used in the
treatment of hypertension and heart failure. This drug promotes the
excretion of sodium and water. ACE inhibitors should not be used in
pregnancy as it reduces the blood flow into the placenta. Care should be
exercised in patients with systolic blood pressure <100mmHg, and creatinine
>250ømol/. Common side effects of these drugs include nausea, dizziness,
diarrhoea, fatigue, headache, hyperkalaemia and tachycardia.
(e) Beta-blockers
This group of drugs are usually indicated for hypertension, angina
pectoris, myocardial infarction and certain types of heart failure with
tachyarrhythmias. All beta-blockers slow the heart rate because it reduces
the output of the blood; therefore, it decreases the work done by the heart.
Beta-blockers should never be given to patients with heart blocks greater
than the first degree. Beta-blockers are also contraindicated for patients
experiencing cardiogenic shock, heart failure with bradycardia and bronchial
asthma.

SYSTEM
"
(f) Anti-arrhythmia Agents

Arrhythmia means absence of heart rhythm and the term is often
interchangeably used with dysrhythmia, which stands for disturbed heart
rhythm. Anti-arrhythmia drugs stabilise the heartbeat back to a normal
pattern. Risks of cardiac arrhythmias are frequent following myocardial
infarction, hypoxia, hypercapnia, or electrolyte imbalances in the body.
There are four classes of arrhythmia agents namely, fast (sodium) channel
blockers, beta-blockers, drugs that prolong repolarisation and calcium
channel blockers.
Quinidine, which is the first drug used to treat arrhythmias, has numerous
side effects like nausea, vomiting, diarrhoea, confusion and hypotension.
Quinidine toxicity should be observed when a patient is taking quinidine.
Patients on quinidine are advised to limit certain foods (for example, citrus
juices, milk and certain vegetables) and avoid over-the-counter drugs (for
example, antacids) because all these will lead to urine alkaline. Alkaline urine
will eventually cause quinidine toxicity, which is signalled by slow pulse.
(g) Drugs Affecting Coagulation

Anticoagulants are drugs that inhibit clot formation in the blood stream by
preventing blood platelet aggregation. On the other hand, thrombolytics are
drugs that dissolve formed blood clots that clog the blood circulation. Close
monitoring is required when children or older adults are given drugs
affecting coagulation. Therapy should be started at the lowest possible level.
Patients are adviced to carry/wear a Medic-Alert notification in case of
emergency. Patients with herbal therapies can be at risk when taking drugs
that affect blood coagulation.
ACTIVITY 3.1
1. What is the normal range of serum potassium (include the unit as

well)?
2. Name a group of drugs used to treat cardiovascular disorders that

can cause serum potassium level depletion.
3. A patient is brought to the Emergency Department with a

potentially life-threatening ventricular arrhythmia. Critically
discuss the immediate treatment for the patient. Share your
findings in the myINSPIRE online forum.

SYSTEM
"
SELF-CHECK 3.1
Describe the precautions to be taken when prescribing diuretics, beta-

blockers and anti-arrhythmia drugs.
3.2 DRUGS FOR HEART FAILURE AND

ARRHYTHMIAS
Heart failure, also known as congestive cardiac failure (CCF), is the end stage of
most diseases of the heart. The incidence of heart failure increases with age.
Although it is not a complete diagnosis by itself, the onset of heart failure can be
chronic or due to acute conditions such as pulmonary oedema or cardiogenic
shock. Cardiac output is the volume of blood passing the heart per minute. In heart
failure, the cardiac output is reduced due to the inability of the heart muscle to
pump out adequate blood into the general circulation to meet the needs of the body
tissue for oxygen and other nutrients. There are two types of heart failures: left
heart failure and right heart failure (refer to Table 3.1).
Table 3.1: Types of Heart Failure
Causes Clinical Features

Left heart failure  Dyspnoea (in acute pulmonary oedema)
 Hypertension  Cough (with or without sputum; sputum is generally
 Aortic valve disease copious, frothy and tinged with blood)
 Coronary artery disease  Raised jugular venous pressure, hepatomegaly,
jaundice, constipation, nausea, vomiting and
peripheral oedema
 Mental confusion and cheyne-stokes respirations
 Oliguria and proteinuria
 Fatigue
 Cyanosis
 Tiredness
 Weakness
Right heart failure  Raised jugular venous pressure
 Chronic bronchitis  Hepatomegaly and jaundice
 Pulmonary valve  Anorexia, nausea and vomiting
disease  Constipation
 Congenital defects  Peripheral oedema

SYSTEM
"
Figure 3.1 shows the cycle of heart failure.
Figure 3.1: Cycle of heart failure

Source: Crouch, Chapelhow and Crouch (2014)
In Malaysia, we have clinical practice guidelines (CPG) produced by Ministry of

Health Malaysia (2007) for the management of heart failure. The management is
divided for:
(a) Acute Heart Failure (AHF); and
(b) Chronic Heart Failure (CHF).

SYSTEM
"
Patients with heart failure typically receive multiple medications to reduce the
cardiac load and improve the pumping efficiency of the heart muscle. Generally,
the most common groups of medications used in treatment of heart failure are
ACE inhibitors, Angiotension II receptor blockers, beta-blockers, diuretics,
inotropes, vasodilators and antiarrhythmic drugs. Other drugs are used as
adjuncts to treat specific symptoms associated with heart failure.
Pharmacological therapy for acute heart failure includes the following:
(a) Frusemide
Intravenous (IV) Frusemide 40 to 100mg. The dose should be titrated
according to clinical response and renal function.
(b) Morphine Sulphate

IV 3 to 5mg bolus to reduce pulmonary venous congestion. It is also useful
for patients who are dyspnoeic and restless.
(c) Nitrates
Nitrates are indicated for as first line therapy in AHF when systolic blood
pressure is above 100mmHg. It should be administered sublingually or
intravenously. However, nitrates are contraindicated in patients with severe
valvular stenosis.
(d) Inotropes
Dopamine infusion: low dose at 2k/kg/min to improve renal flow and
promote dieresis. Dobutamine infusion is titrated until the desired clinical
and hemodynamic response is achieved.
(e) Vasodilators
Sodium Nitroprusside will be used if patient is not responsive to nitrates.
If the systolic blood pressure drops to below or remains at level of 100mmHg,

dopamine infusion and adrenaline/noradrenaline infusion should be considered.
In such circumstances, vasodilators (nitrates and nitroprusside) and morphine
should be avoided until the blood pressure is stabilised. After initial clinical
assessment of vital signs, treatment of acute heart failure should be instituted as
outlined in Figure 3.2.

SYSTEM
"
Figure 3.2: Flowchart for the management of acute heart failure

(acute cardiogenic pulmonary oedema)
Source: Ministry of Health Malaysia (2012)

SYSTEM
"
Pharmacological therapy for chronic heart failure includes the following:
(a) Diuretics
To reduce signs and symptoms of fluid retention.
(b) ACE Inhibitors

Is given especially to patients with left ventricular dysfunction as reflected
by an LV ejection fraction of <40 per cent. Central management of heart
failure includes the use of ACE inhibitors. ACE inhibitors inhibits the
production of angiotensin II, thus effectively lowering the blood pressure. It
is particularly indicated for hypertension among diabetic patients with
nephropathy.
In some cases, the patients will experience a very rapid fall in blood pressure
which is known as „first-dose hypotension‰. Therefore, treatment should be
commenced at low dose and to be taken at bedtime. ACE inhibitors are
divided into short-acting and long-acting types. Short-acting ACE inhibitors
such as captopril, are to be taken two to three times daily. Long-acting ACE
inhibitors such as lisinopril and ramipril are to be taken only once a day.
Side effects are well tolerated in general and if dry cough is unresponsive to
antitussives, ACE inhibitors should be discontinued. Some patients may
report taste disturbance, which is characterised by a metallic taste in the first
one to three months of initiating therapy.
(c) Beta-blockers
Beneficial in heart failure by blocking sympathetic activity. It is used when
pulmonary congestion is absent and patient appears clinically stable.
(d) Digoxin
Is indicated for heart failure patients with atrial fibrillation. Low dose should
be used in the elderly and patients with renal impairment.
(e) Anti-coagulation Therapy

Heart failure patient with risk factors of thromboembolisms should be given
anti-coagulants such as warfarin, unless there are contraindications.
(f) Calcium Channel Blockers

Such as amlodipine and felodipine may be considered in cases with
concurrent hypertension and angina.
Drug therapy is the mainstay of management of chronic heart failure as outlined

in Figure 3.3.

SYSTEM
"
Figure 3.3: Optimising drug therapy in chronic heart failure


SYSTEM
"
Do you know what arrhythmia is? Arrhythmia is a term that denotes changes
in heart rate (tachycardia or bradycardia) that may be due to conditions such
as premature ventricular contractions (atrial flutter, atrial fibrillation and
ventricular fibrillation), or alterations in conduction through the muscle (heart
blocks and bundle brunch blocks). Therefore, anti-arrhythmic agents are used in
emergency situations when the hemodynamic disruptions arise and could lead to
potentially fatal consequences.
Anti-arrhythmias agents are classified into the following classes:
(a) Class 1A (Disopyramide, Moricizine, Procainamide, Quinidine);
(b) Class 1B (Lidocaine, Mexiletine); and
(c) Class 1C (Flecainide, Propafenone).
Now, let us see if you can challenge your mind with some word puzzle!
ACTIVITY 3.2
1. Unscramble the following letters to form the names of commonly

used anti-arrhythmias agents:
(a) Namedooria;
(b) Moolesl; and
(c) Onidigx.
2. X is frequently used to treat ventricular arrhythmias in emergency

situations and is also a commonly used local anaesthetic. What is
X?
3. Discuss the advice to a patient taking digoxin for treatment of

chronic heart failure.
4. While monitoring Mr F after oral digoxin administration, you, as

the nurse in-charge, notice increased urinary output, reduced
dyspnoea and fatigue, but Mr F still complains of constipation.
He says that if he was allowed to eat bran as often as he used to do
at home, he would not be constipated. How would you respond to
Mr F?

SYSTEM
"
SELF-CHECK 3.2
1. Describe the common pharmacological therapy for acute heart

failure and chronic heart failure.
2. List the three classes of anti-arrhythmia agents.
3.3 DRUGS FOR DISORDERS OF BLOOD

COAGULATION
Drugs used for treating the disorders of bold coagulation include the following:
(a) Anticoagulants
Anticoagulants will disrupt the coagulation process by interfering with the
clotting cascade and thrombin formation. Examples of drugs in this class
include the following:
(i) Warfarin (given orally);
(ii) Heparin (administered parenterally); and
(iii) Antithrombin (administered parenterally).
If a patient who is taking an anticoagulant presents with profound bleeding

but no other cause is found, you must always rule out the possibility of the
patient consuming herbal therapies.
(b) Antiplatelet Drugs

Antiplatelet drugs are used effectively to treat cardiovascular diseases,
which are precipitated by clumping of platelets to form clots that eventually
occlude blood vessels. For example, if the clot occludes the
blood flow to any part of the brain, then a serious condition known as
cerebrovascular accident or stroke results from the occlusion. Examples of
drugs that reduce the clumping of blood platelets that produce clots include
aspirin, abciximab, clopidogrel and dipyridamole.

SYSTEM
"
(c) Thrombolytics
Thrombolytic agents help to dissolve the clot to open the blood vessel, thus,
restoring the blood flow to the affected area. Thrombosis is a condition when
a blood clot occludes the blood flow in the coronary arteries that causes acute
myocardial infarction. Streptokinase is a commonly used thrombolytic agent
to treat coronary artery thrombosis associated with acute myocardial
infarction.
ACTIVITY 3.3
1. Describe the action of Vitamin K in reversing the effects of

Warfarin?
2. What is the antidote for heparin overdose?
3. After experiencing transient ischaemic attack (TIA), Mr D has been

started on Clopidogrel (Plavix). He has history of atherosclerotic
heart disease and has problems with peptic ulcer disease. What is
the rationale of commencing Clopidogrel to Mr D instead of
Aspirin?
SELF-CHECK 3.3
Tick „True‰ or „False‰ for the following statements.
Statement True False

1. Plasminogen is the basis of the coagulation cascade.
2. Anticoagulants dissolve clots that have formed in the
blood stream.
3. Thrombolytic agents block coagulation and prevent the
formation of clots.
4. The final step of clot formation is the conversion of
prothrombin to thrombin, which breaks down
fibrinogen to form soluble fibrin threads.

SYSTEM
"
3.4 DRUGS FOR CORONARY ARTERY DISEASE

AND STROKE
The main forms of cardiovascular disease are coronary heart disease (CHD) and
stroke. We will discuss the drugs used in treatment of CHD such as hypertension,
angina and myocardial infarction. Cardiac failure is a possible complication of
CHD as we have already discussed in the earlier section of this topic.
As we have seen earlier in the topic, Beta-blockers are used extensively in treating
hypertension, angina and myocardial infarction. Beta-blockers lower the diastolic
blood pressure to less than 95mmHg in about 40 to 50 per cent of patients with
mild to moderate hypertension.
Mechanism of Beta-blockers in treating hypertension includes the following:
(a) Reduction of cardiac output;
(b) Resetting the baroreceptors;
(c) Suppression of renin (to produce angiotensin and a vasoconstrictor

hormone); and
(d) Release of vasodilator prostaglandins.
For treating angina, Beta-blockers act to reduce the heart rate, thus reduce the
cardiac cycle and increase the diastolic interval. This, in turn, will allow for better
coronary perfusion.
Now, let us learn about stroke. There are two types of stroke as shown in
Figure 3.4.
Figure 3.4: Types of stroke

SYSTEM
"
Another condition called transient ischaemic attack (TIA) is a minor episode of

stroke. TIA lasts for a few minutes or hours; however, some people may experience
catastrophic results such as death or severe disability following TIA. Hypertension
is the major risk of stroke. Drug management that reduces the risk of stroke among
patients with hypertension includes anticoagulants such as aspirin. Table 3.2
highlights the therapeutic agents available in Malaysia for the management of
ischaemic stroke.
Table 3.2: Therapeutic Agents Available in Malaysia
Therapy Drugs
Anti-platelets  Cyclo-oxygenase inhibitors
⁄ Acetylsalicylic acid (Aspirin)
⁄ Triflusal (new)
 Adenosine Diphosphate Receptor Antagonists
⁄ Ticlodipine
⁄ Clopidogrel
 Other Antiplatelets Agents
⁄ Dipyridamole
⁄ Cilostazol (new)
Anticoagulants IV  Unfractionated Heparin (UFH)
⁄ Heparin
 Low Molecular Weight Heparin (LMWH)
⁄ Nadroparin
⁄ Enoxaparin
⁄ Fondaparinux
Oral  Low Molecular Weight Heparin (LMWH)
⁄ Warfarin
⁄ Dabigatran Etexilate (new)
Thrombolytics Recombinant-tissue plasminogen activator (rtPA)
 Alteplase

SYSTEM
"
ACTIVITY 3.4
1. Did you know that the Stroke Council Malaysian Society of

Neurosciences (MSN) has recommended 9 KPIs for stroke? Can
you list the 9 KPIs recommended?
2. Mr W, 48-year-old, is being admitted for deep vein thrombosis

(DVT) of the left lower extremity. He is on a weight-based heparin
protocol. As a nurse in-charge of Mr W, explain why the weight-
based heparin protocol is being used for him? What are the
pertinent lab values that would help to establish the care for Mr W?
3. You are reviewing the use of anticoagulants for a teaching session

for new staff at your unit. Select from the following conditions
where anticoagulant therapy is appropriate for use (you can choose
more than one answer).
(a) Atrial fibrillation
(b) Thrombocytopenia
(c) Myocardial infarction
(d) Presence of mechanical heart valve
(e) Leukaemia
(f) Aneurysm
4. A patient is at risk of stroke. Which drug is recommended to

prevent platelet aggregation for stroke prevention?
Discuss and share your answers in the myINSPIRE online forum.
"

SYSTEM
"
3.5 DRUGS FOR SHOCK

Shock is a life-threatening condition when the body is not getting enough blood
flow. This abnormality of the circulation system will result in insufficient tissue
perfusion due to disrupted oxygen delivery. Therefore, shock requires immediate
medical attention to prevent the patientÊs condition from worsening very rapidly.
Initial stage of shock is called compensated shock. However, this phase will
progress rapidly to decompensated shock if it is left untreated whereby the patient
becomes hypotensive and develops tachycardia. Hence, the hypotensive state is a
late finding of shock. Figure 3.5 shows the five main types of shock.
Figure 3.5: Types of shock
Table 3.3 outlines the general management for the different types of shock.
Table 3.3: General Management for Shock
Types of Shock Treatment
Cardiogenic shock Fluid + Chronotropic drugs + Inotropic drugs + Vasoconstrictors

+ KIV vasodilators
Hypovolemic Haemorrhage control + Fluid resuscitation + Blood products +

shock KIV surgery
Anaphylactic Fluid + Epinephrine + Antihistamines + Steroids

shock
Septic shock Fluid + Vasoconstrictors + Inotropic drugs + Antibiotic + KIV

surgery
Neurogenic shock Fluid + Vasoconstrictors

SYSTEM
"
Table 3.4 describes the sympathomimetic drugs used for treating severe
hypotension and shock.
Table 3.4: Descriptions of Sympathomimetic Drugs

Used for Treating Severe Hypotension and Shock
Drugs Description
Dopamine It stimulates the heart and blood pressure. However, it will cause
renal and splanchnic arteriole dilation. Thus, increases blood flow
to the kidneys, preventing the diminished renal blood supply and
possible kidney shutdown will occur.
Dobutamine It increases myocardial contractility without much change in rate,

does not increase oxygen demand of cardiac muscle. Therefore, it is
superior choice for treatment of congestive heart failure.
Ephedrine It stimulates the release of norepinephrine from nerve endings,

which will directly act on adrenergic receptors. However, its use is
declining due to availability of less toxic drugs with more
predictable onset and action.
Epinephrine It increases blood pressure and cardiac contractility.
Norepinephrine Treating shock or during cardiac arrest by stimulating sympathetic

activity.
Metaraminol It prevents hypotension by increasing the myocardial contractility

and causing peripheral vasoconstriction.

SYSTEM
"
ACTIVITY 3.5
1. Mr A and Mr B are both on Dopamine infusions. Mr AÊs infusion is

being administered at low rate, but Mr BÊs infusion is at a higher
rate. Explain the rationale why these dopamine rates might be
infused at different rates. Relate your answer to the functions of
dopamine.
2. Mr G, a 45-year-old factory worker, is brought into the Emergency

Department for leg ulceration. He was treated with Penicillin and
starts to wheeze. He says, „Oh, I just remembered that I am allergic
to Penicillin!‰
(a) What is the possible cause of wheezing in Mr G?
(b) What should you do first as the nurse providing immediate

care for Mr G?
(c) What are the common drugs to be given to stabilise the

condition of Mr G in this situation?
Share your answers in the myINSPIRE online forum.
SELF-CHECK 3.4
Madam A has been admitted to HDU for close monitoring. Her blood
pressure has continued to drop despite administration of IV fluids.
IV Dopamine has been started for her. Explain the functions of Dopamine
to Madam A.
"

SYSTEM
"
 Cardiovascular diseases have become the number one killer in Malaysia in

terms of health-related problems.
 Specific precautions are required for patients taking medicine for

cardiovascular diseases, such as diuretics, morphine, ACE inhibitors, beta-
blockers and drugs affecting coagulation.
 Heart failure is caused by left heart failure or right heart failure.
 Drugs for acute heart failure include frusemide, morphine, nitrates, inotropes
and vasodilators. Dopamine, adrenaline/noradrenaline must be considered if
the patientÊs systolic blood pressure is less than 100mmHg.
 Drugs for chronic heart failure include diuretics, ACE inhibitors, beta-blockers,
digoxin, anti-coagulant and calcium channel blockers.
 Arrhythmias can be caused by the changes in rate or premature ventricular

contractions. Quinidine toxicity must be observed when the patient is taking
quinidine.
 For a patient who is taking anticoagulants, always question the patient on

the possibility of herbal therapies if the patient has profound unidentified
bleeding. Examples of anticoagulants are warfarin, heparin, aspirin and
streptokinase.
 Drugs management for stroke includes treating hypertension, aspirin and

cholesterol lowering drugs.
 Shock can be categorised as compensated shock and uncompensated

shock. Sympathomimetic drugs such as dopamine, dobutamine, ephedrine,
epinephrine, norepinephrine and metaraminol, can be used to treat severe
hypotension and shock.
" "

SYSTEM
"
Arrhythmias Myocardial contractility

Cardiac output Renal perfusion
Compensated shock Sympathetic activity
Decompensated shock Vasodilators
Inotropes
Crouch, S., Chapelhow, C., & Crouch, M. A. (2014). Medicines management:

A nursing perspective. London, England: Routledge.

Ministry of Health Malaysia. (2007). Clinical practice guidelines: Management of

heart failure (2nd ed.). Retrieved from http://www.acadmed.org.my/
view_file.cfm?fileid=254

of ischaemic stroke (2nd ed.). Retrieved from http://www.moh.gov.my/
attachments/7496.pdf
The Star Online. (5 April, 2015). LetÊs spread happiness and „Live Great‰.
Retrieved from http://www.thestar.com.my/lifestyle/health/2015/04/
05/lets-spread-happiness-and-live-great/
Yayasan Jantung Malaysia. (2015). The Heart Foundation of Malaysia. Retrieved

from http://www.yjm.org.my/index.cfm?menuid=2

Topic
" " "
" Pharmacotherapy
"
"
"
"
for Conditions
4
"
"
"
"
of the Respiratory
"
"
"
System
"
"
" LEARNING OUTCOMES
"
" 1. Explain the use of systemic corticosteroids for home and hospital
" management of acute exacerbations of COPD;
"
" 2. State the drugs commonly used for mild to moderate pain;
" 3. Discuss the effects of drug distribution on the liver function of
" paediatric patients;
"
" 4. Describe how the respiratory function is affected during pregnancy;
" and
" 5. Explain the effects of aging on the liver and its functioning in drug
" therapy.
"
 INTRODUCTION
Do you still remember the haze blanketing several countries in South East Asia for
a few months in 2015? How would the haze condition have affected the lifestyles
of people in those countries? Can you imagine the harmful effects of the haze to
our general health and to our respiratory system in particular? Although we are
aware that some respiratory disorders are due to genetic anomalies, the majority
of the risk factors for respiratory diseases arise from the unhealthy
environment (occupational dusts and pollution), poor personal habits (tobacco
smoking), certain socioeconomic factors, infections and oxidative stress. In this
module, we will discuss some conditions related to respiratory system disorders.

72  TOPIC 4 PHARMACOTHERAPY FOR CONDITIONS OF THE RESPIRATORY
SYSTEM
"
The respiratory system is also known as the pulmonary system and these terms
are used interchangeably. Obstruction of the airway is a major cause of respiratory
system disease. Examples of pulmonary obstructive diseases include asthma,
chronic obstructive pulmonary disorder (COPD), cystic fibrosis and respiratory
distress syndrome (RDS). COPD is also known as chronic obstructive airway
disease (COAD). As the abbreviation COPD is commonly used, we will maintain
using COPD throughout this topic.
4.1 SPECIFIC PRECAUTIONS FOR

MEDICATIONS RELATED TO RESPIRATORY
SYSTEM DISORDERS
Caution should be exercised during severe acute exacerbation of COPD
(AECOPD) when giving intravenous aminophylline to the patient. If a patient who
is already on maintenance dose of theophylline, she or he should not be given an
additional loading dose of aminophylline. Thorough history taking should be
performed prior to any additional pharmacological therapy in such cases. It is
important to note that theophylline has a narrow margin between therapeutic dose
and toxic dosage. The patient should be monitored for serum theophylline levels
during the treatment in order to prevent toxicity from overdose. In order to achieve
satisfactory bronchodilation, patients are required to have a plasma theophylline
concentration of 10ă20mg/L.
Patients with theophylline/aminophylline should be monitored for the following

signs:
(a) Nausea;
(b) Insomnia;
(c) Palpitation;
(d) Arrhythmias; and
(e) Convulsions.
"

TOPIC 4 PHARMACOTHERAPY FOR CONDITIONS OF THE RESPIRATORY  73
SYSTEM
"
Such side effects are precipitated by theophylline toxicity if plasma theophylline

concentration rises above 20mg/L. Due to its variation of half-life, theophyline
should be used with caution in patients with hepatic impairment, heart failure and
concomitant therapy with certain drugs like phenytoin, carbamazepine, rifampicin
and barbiturates.
Diphenhydramine and chlorpheniramine are classified as H1-antihistamines

and they have sedative qualities. Benadryl, which is the trade name for
diphenhydramine, is a common cough remedy. However Benadryl is found to
have significant central nervous system (CNS) depressant effects. It also leads to
an immediate onset of drowsiness, hypotension and dry mouth. Codeine
(an opioid drug), is another antitussive drug that suppresses cough through direct
action on the cough centre in the medulla oblongata of the central nervous system,
thus leading to significant CNS and respiratory depression.
Patients who are prescribed with bronchodilators should exercise caution with the
use of the drug as headaches, nervousness, restlessness, hands tremor,
palpitations, tachycardia and insomnia are known side effects from overdose
or when not adhering to specific precautions. Patients who are prescribed with
inhalant corticosteroids must be warned of dry mouth, hoarseness and
oropharyngeal fungal infections (candida). Long-term use with high dose of such
steroids will lead to peptic ulcer, Cushingoid syndrome, decreased wound healing
rates and glaucoma.
4.2 DRUGS FOR CHRONIC OBSTRUCTIVE

AIRWAY/PULMONARY DISEASE (COPD)
Chronic obstructive airway or pulmonary disease is anticipated to rank fifth by
2020 in terms of burden of diseases worldwide, according to a study published by
the World Bank, World Health Organisation and Harvard School of Public Health
(1996). COPD is usually precipitated by chronic cigarette smoking. It is a
permanent, chronic obstruction of the airways. Emphysema and chronic bronchitis
are also major causes of COPD. Both of these conditions cause airway obstruction
during expiration, whereby the exhalation process causes overinflation of the
alveoli in the lungs and thus leading to poor gas exchange. Figure 4.1 shows the
changes to the bronchioles and alveoli in COPD.

SYSTEM
"
Figure 4.1: Distended and overinflated alveoli versus healthy alveoli in COPD
Source: http://www.bupa.co.uk/health-information/directory/c/copd
The Ministry of Health Malaysia (2009) has outlined the management of COPD
with emphasis on the following:
(a) Early diagnosis through targeted spirometry tests and early intervention
including smoking cessation even in mild COPD;
(b) Improving dyspnoea and activity limitation in stable COPD using up-to-date
evidence-based treatment algorithms; and
(c) Preventing and managing acute exacerbations, particularly in more severe

COPD.
"

SYSTEM
"
Bronchodilators are the best option of pharmacological therapy in COPD.

Table 4.1 presents a brief summary on the management for acute exacerbations of
COPD (AECOPD) for home care.
Table 4.1: Description of Home Management

for Acute Exacerbations of COPD (AECOPD)
Treatment Description
Bronchodilator  Inhaled bronchodilators improve airflow obstruction and reduce
therapy lung hyperinflation, therefore improving dyspnoea. Short-acting
inhaled 2-agonists (SABA), are preferred for treating AECOPD.
 The dosage and frequency of existing SABA therapy should be
increased, such as salbutamol or terbutaline every three to four
hours.
 Anticholinergic therapy such as ipratropium bromide may be
added if not yet in use, until the symptoms improve.
Systemic  Should be used in addition to with existing bronchodilator
corticosteroids therapy to improve dyspnoea, shorten recovery time, improve
oxygenation, improve lung function and reduce treatment failure.
 A dose of 30 to 40mg prednisolone per day for one to seven days
is appropriate for most patients.
Antibiotics  Bacteria of lower respiratory tract infections following an initial
viral infection are common in AECOPD.
 Antibiotics should be given to AECOPD patients with at least two
out of three cardinal symptoms (purulent sputum, increased
sputum volume and/or increased dyspnoea). The choice of
antibiotics depends on local antibiotic policy.
Expectorants Used to assist in loosening the mucus lodged in the airways that
constrict the airflow.
Table 4.2 presents a brief summary on the management for acute exacerbations of
COPD (AECOPD) for hospital care.
"

SYSTEM
"
Table 4.2: Description of Hospital Management
for Acute Exacerbations of COPD (AECOPD)
Treatment Description
Bronchodilator  Inhaled SABA (salbutamol, fenoterol or terbutsline) is usually
therapy given in nebulised form.
 In case of severe AECOPD, nebulised SABA can be combined with
a short acting anticholinergics (SAAC), such as:
⁄ Combivent® nebuliser solution 2.5ml (ipratropium bromide +
salbutamol); or
⁄ Duovent® nebuliser solution 4ml (ipratopium bromide +
fenoterol).
 If inadequate response to inhaled SABA and SAAC, intravenous
methylxanthines (aminophyline or theophylline) will be
considered.
 The relief of airflow obstruction by bronchodilator therapy is the
major goal in the treatment of AECOPD.
Systemic  A dose of 30 to 40mg prednisolone per day for one to seven days
corticosteroids is safe and effective. Nebulised corticosteroids may also be
beneficial during AECOPD as an alternative to oral prednisolone.
 Systemic corticosteroids improve lung function over first 72 hours,
shorten hospital stay and reduce failure of the treatment over the
subsequent 30 days.
Antibiotics  Bacteria of lower respiratory tract infections following an initial
viral infection are common in AECOPD.
 Antibiotics should be given to AECOPD patients with at least two
out of three cardinal symptoms (purulent sputum, increased
sputum volume and/or increased dyspnoea). The choice of
antibiotics depends on the local antibiotic policy.
Expectorants Used to assist in loosening the mucus lodged in the airways that
constrict the airflow.
Controlled  Controlled oxygen therapy of 24 to 28 per cent oxygen via Venturi-
oxygen therapy mask to ensure accurate oxygen delivery or 1 to 2L/min of oxygen
via nasal prongs. Arterial blood gases should be monitored
regularly base on patientÊs clinical state.
 Oxygen therapy is given to maintain adequate oxygenation without
precipitating respiratory alkalosis and worsening hypercapnia.
Figure 4.2 shows the algorithm for managing acute exacerbations of COPD
specifically for home management. Figure 4.3 shows the algorithm for managing
acute exacerbations of COPD focusing on hospital management.

SYSTEM
"
Figure 4.2: Algorithm for managing AECOPD: Home management


SYSTEM
"
Figure 4.3: Algorithm for managing AECOPD: Hospital management


SYSTEM
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ACTIVITY 4.1
1. If a patient is prescribed to take inhaled steroids, an anticholinergic

inhaler, and a beta-adrenergic agonist inhaler, which inhaler would
you tell the patient to use first? Why? Discuss your answer with
your coursemates in the myINSPIRE online forum.
2. Mr K, a 60-year-old teacher, has history of arthritis, glaucoma and

emphysema. The physician is planning a prophylactic treatment for
his emphysema in order to prevent COPD.
(a) Name three types of drugs that might be considered for

treatment of COPD.
(b) Which condition (of those three medical conditions

mentioned above) must the physician be cautious of when
determining the best drug for Mr K?
SELF-CHECK 4.1
1. Discuss the use of systemic corticosteroids for home and hospital

management of acute exacerbations of COPD.
2. How is the controlled oxygen therapy used for treating acute

exacerbations of COPD in the hospital? Explain.
4.3 DRUGS FOR INFLAMMATION, FEVER AND

ALLERGIES
Allergic conditions vary from mild forms such as hay fever, skin rashes and
eczema to more severe forms such as asthma and anaphylactic shock. As we have
already discussed anaphylactic shock in Topic 3, here we will focus more on the
treatment for asthma. As inflammation and allergies affecting the respiratory
system are inter-connected in their pathophysiological responses, we will combine
the discussion on their management. In the following subtopics, we will discuss
the drugs for asthma, allergy-induced rhinitis, fever and inflammation.

SYSTEM
"
4.3.1 Drugs to Treat Asthma

Asthma that is due to allergic disorders has a strong family tendency. Asthma
which occurs later on in life is not due to allergic causes, and it is called intrinsic
asthma. It normally affects older patients. Allergens that provoke response in
certain individual are shown in Figure 4.4.
Figure 4.4: Examples of allergens that provoke response in susceptible individuals
Asthma is another common condition that puts an intense burden on healthcare

resources. The major symptoms of asthma include wheezing, shortness of breath,
chest tightness, cough which is worse at night and it is often provoked by trigger
factors such as exercise or certain food or other known allergens (Malaysian
Thoracic Society, 1996). Asthma can be categorised as early onset (allergen related)
and late onset (non-allergen related). Table 4.3 outlines the drugs which are
commonly used for managing asthma.
"

SYSTEM
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Table 4.3: Drugs Used in the Management of Asthma

Drug Description
2 Agonists Acts directly to stimulate 2 receptors in the smooth muscle of the
airways which in turn will produce bronchodilation. Separately, 2
agonist also will stabilise mast cells to prevent the release of
inflammatory mediators and histamine as a result of exposure to
allergens.
Antimuscarinic Such as inhaled ipratropium bromide (Atrovent), may be added to
bronchodilators other standard treatment in life-threatening asthma. These drugs
are anticholinergic agents that combine with β2 agonists to prolong
duration of bronchodilation.
Theophylline Acts by inhibiting the enzyme phosphodiesterase in bronchiole
muscle and leads to relaxation and relieve of bronchospasm.
Besides its bronchodilator effects, it also has anti-inflammatory
effects.
Corticosteroids Act by inhibiting various types of inflammatory agents, to reduce
the inflammatory response of asthma and decrease bronchospasm.
Cromolyn Possess anti-inflammatory actions that inhibit the release of
substances from mast cells that are responsible for bronchospasm.
Leukotriene Blocks stimulation of bronchial smooth muscle, blocks release of
receptor eosinophils and production of secretions in the airways, thus,
antagonists relieving bronchoconstriction and prevent inflammation especially
that which is induced by exercise or allergen triggered asthma.
Let us look at the administration of the following drugs for asthma (Downie,
Mackenzie, Williams & Hind, 2008):
(a) 2 Agonists
Patients with mild and moderate symptoms of asthma usually respond
promptly to the inhalation of selective short-acting 2 agonist like
salbutamol. Salbutamol is indicated for Step 1 of asthma management
because of its rapid onset of action (approximately 15 minutes) and their
effects last for four to six hours. If salbutamol is required three or more doses
in a week, the management should move on to Step 2, where inhaled
corticosteroid agents will be prescribed. This intervention is especially
appropriate for patients with recent exacerbations, nocturnal asthma,
impaired lung function, and/or patients requiring salbutamol for more than
three times a week. Step 3 involves using long-acting 2 agonist on a regular
basis with combination of inhaled corticosteroids. Steps 1 to 3 are shown in
Figure 4.5 and it is based on the recommendations of British Thoracic Society
and Scottish Intercollegiate Guidelines Network (2014).

SYSTEM
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Figure 4.5 shows the summary of stepwise management of asthma in adults.
Figure 4.5: Stepwise management of asthma in adults

Source: British Thoracic Society and Scottish Intercollegiate Guidelines Network (2014)
(b) Antimuscarinic Bronchodilators

Ipratropium can provide short-term relief in chronic asthma, but short acting
2 agonists act more quickly and are preferred. Antimuscarinic
bronchodilators are regarded as being more effective in relieving
bronchoconstriction associated with COPD than in relieving asthma.
(c) Theophylline
This is a bronchodilator used for reversible airway obstruction. It is used in
step 3 of the asthma management. Patients with nocturnal asthma may
benefit from theophylline in slow-release preparations which will aid in
therapeutic plasma concentrations overnight. As mentioned earlier, because
of its narrow margin between therapeutic and toxic dosage, patients are
required to have a plasma theophylline concentration of 10 to 20mg/L in
order to achieve satisfactory bronchodilation. Thus, a dose of 125 to 250mg

SYSTEM
"
three to four times daily will be prescribed after food. In intravenous form,
theophylline is given as aminophylline due to its concentration (20 times
more soluble than theophylline alone) as aminophylline is too irritant to be
given intramuscular.
(d) Corticosteroids
Inhaled corticosteroids are best started at high dose (via metered dose
inhaler) and reduced gradually when control is achieved. If the patient is
using 2 agonist inhaler and inhaled corticosteroid concurrently, the 2
agonists should be advised for first use. The rationale for this is because
outcomes of bronchorelaxation will result in a more effective dose of inhaled
corticosteroid.
(e) Cromolyn
Also known as mast cell stabilisers due to its mode of action to inhibit the
release of substances from mast cells which result in bronchospasm.
Cromolyns are most effective for atopic asthma (exercise-induced or
allergen-induced) because they inhibit bronchospasm during and after
exercise and also when exposed to cold or dry air.
(f) Leukotriene Receptor Antagonist

Leukotriene receptor antagonist blocks stimulation of bronchial smooth
muscle, release of eosinophils and production of secretions in the airways,
thus, relieves smooth muscle bronchoconstriction and prevents
inflammation. Montelukast and zafirlukast are indicated for the prophylaxis
of asthma. Leukotriene receptor antagonist is also useful for preventing
exercise-induced asthma and aspirin-sensitive asthma.
ACTIVITY 4.2
A patient with status asthmaticus has not yet responded to epinephrine.

What is the drug that the nurse should anticipate to use next? Explain
your choice in the myINSPIRE online forum.
"

SYSTEM
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4.3.2 Drugs to Treat Allergy-induced Rhinitis

Antihistamines are very effective for allergy induced rhinitis. They block the action
of histamine that would have been released during the inflammatory phase as a
reaction to an antigen. Antihistamines can be classified as first and second
generation drugs. Antihistamines are available as over-the-counter (OTC)
medications; therefore, they are commonly misused to treat cold and influenza.
The examples of first and second generations of antihistamine agents are as shown
in Table 4.4.
Table 4.4: First and Second Generation of Antihistamine
Classification Agents
First generation antihistamine  Diphenhydramine
 Brompheniramine
 Chlorpheniramine
Second generation antihistamine  Fexofenadine
 Loratidine
 Cetirizine
4.3.3 Drugs to Treat Fever and Inflammation

As fever and inflammation are directly related to the respiratory system
pathology, we will discuss both of these as part of the symptoms when the patients
are having respiratory disorders. During fever, the hypothalamus resets our body
mechanism to tolerate higher temperature. At the same time, when fever is
present, our body will stimulate more prostaglandin secretion in the cells, which
cause changes in to the lumen of the airways.
Inflammation response, on the other hand, can be due to various types of stimuli-
trauma, infection, surgery and ischemia. Inflammation has five cardinal signs
which include swelling, heat, redness, pain and loss of function. Physiological
response of inflammation will not be discussed here. However, inflammation is
also worsened by the rupture of mast cells, such as in allergies. This will lead to
release of biochemical mediators like histamine, prostaglandins and leukotrienes
that cause bronchoconstriction.
"

SYSTEM
"
Salicylates and prostaglandin synthetase inhibitors (PSI) drugs are commonly

used to treat inflammation and fever in various conditions, including respiratory
disorders. Aspirin, for example, is commonly used for mild to moderate pain. PSIs
have anti-inflammatory effects and analgesics properties as PSIs are a subgroup of
NSAIDs. Examples of PSIs are ibuprofen, diclofenac sodium (Voltran),
indomethacin, ketolorac and many more.
ACTIVITY 4.3
Match the following words with the correct statement.
Theophylline Cetirizine
Acetylsalicylic acid Relief of wheezing
(a) What is the best outcome after a nurse administers bronchodilator

to a patient with acute asthma attack?
(b) An asthmatic patient was diagnosed with hyperthyroidism. Which

medication should be prescribed with caution?
(c) What drug is commonly used for mild to moderate pain?
(d) Give an example of a second generation antihistamine.
4.4 SAFETY ALERTS FOR MEDICATIONS OF

RESPIRATORY SYSTEM IN ALL AGE
GROUPS
In this subtopic, we will discuss further the safety alerts for all age groups:
children, pregnant and breastfeeding and elderly patients.
4.4.1 Management for Children

Management for drug therapy in respiratory system disorders for children is
different from adults in many ways. Paediatric patients are classified as
individuals who are younger than 16 years old and weigh less than
50 kilograms. Table 4.5 discusses the management of drug therapy in children.
"

SYSTEM
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Table 4.5: Management of Drug Therapy in Children
Core Drug Knowledge Description

Pharmacotherapeutics Dose calculation of drug therapy in paediatric patient is
mainly based on „milligrams of drug per kilogram of body
weight (mg/kg)‰. In isolated cases, dosage of some drugs in
children can be determined by body surface area.
Pharmacodynamics Younger children have immature organ systems to optimise
the protective function. As such, drug dosage should be
reviewed to prevent toxicity and to achieve therapeutic level
of the child.
Pharmacokinetics As the child grows, the body maturity can affect the function
of the absorption, distribution, metabolism and excretion of
the drugs prescribed.
Absorption Drug absorption in paediatric patients is determined by
various factors such as age, disease process, dosage form,
route of administration, food consumed and existing drugs
present in the childÊs body.
Distribution Distribution of drug in paediatric patients is different
because of the differences in body water and fat composition
of the childÊs body, immature liver function and immature
blood-brain barrier.
Metabolism Most drugs are metabolised in the liver. However, due to
immaturity of neonatal and infantÊs liver, the metabolism of
many drugs are decreased or incomplete. Therefore,
lowering the drug dosages or increasing the interval of the
drugs would help in achieving appropriate therapeutic
levels.
Excretion Most drugs are excreted from the body through the urine. In
children with immature renal (for example, preterm infant)
or impaired renal function, drug dosages should be altered
to achieve the therapeutic levels. Separately, therapeutics
drugs levels should be monitored closely to prevent toxicity.
Source: Aschenbrenner and Venable (2012)
SELF-CHECK 4.2
1. What is the definition of „paediatric patient‰ in relation to drug

therapy?
2. How does the liver function in children affect drug distribution?

SYSTEM
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4.4.2 Drug Therapy for Pregnant and Breastfeeding

Mothers with Respiratory Problems
Drug therapy of the respiratory system disorders in pregnant and breastfeeding
mothers is challenging because most drugs pass through the placenta membrane
to the foetus or pass through breast milk to the infant. The healthcare providers
must keep in mind that the greatest risk for drug-induced developmental defects
occurs during the first trimester of pregnancy. Table 4.6 discusses the management
of drug therapy in pregnant and breastfeeding mothers.
Table 4.6: Management of Drug Therapy for Pregnant and Breastfeeding Mothers
Pharmacotherapeutics The important considerations in terms of

pharmacotherapeutics in pregnant women are the potential
adverse effects on the developing foetus.
Pharmacokinetics Pregnant women will experience several physiologic and

anatomic changes. These changes will alter the
pharmacokinetics of the drugs which involve the endocrine,
gastrointestinal (GI), cardiovascular, circulatory and renal
systems.
Absorption Influences of pregnancy-related hormones and mechanical

pressure of the growing foetus will cause changes in GI
system. Effects of oral drugs therapy for the respiratory
system during pregnancy will be altered due to effect of
progesterone which decreases gastric tone, motility and
prolongs duration of stomach emptying. Respiratory
functions will be affected too during pregnancy. Tidal
volume of the lungs increases 30 per cent to 40 per cent
in early pregnancy and 50 per cent by term. Therefore,
inhaled respiratory drugs during pregnancy will be affected
along with pulmonary vasodilation that occurs.
"
" "

SYSTEM
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Distribution and Hemodynamic changes in cardiovascular system during

Metabolism pregnancy will alter increment of heart rate approximately
10 to 15bpm above baseline, thus, increasing the blood
volume to 40 per cent. Drugs may compete with the
pregnancy hormones for albumin-binding sites. This will
cause large amount of unbound drugs freely circulate and
available to cross the placental membrane and foetal
circulation. In nursing mothers, lipophilic drugs (fat soluble)
pass easily because breast milk contains high percentage of
fat. However, despite alteration in distribution, drug
metabolism is not altered in pregnant or breastfeeding
mothers.
Excretion During pregnancy, changes in renal function occur,

especially in the third trimester. Increase in renal blood flow
cause increase in glomerular filtration rate, thus, this will
contribute to greater excretion rates in a pregnant woman.
SELF-CHECK 4.3
1. Discuss how the respiratory function is affected during pregnancy.
2. Explain why lipophilic drugs are more likely to enter breast milk
than non-lipophilic drugs.
3. Describe the excretion process in pregnant women.
4.4.3 Management of Drugs Therapy for the Elderly

Drugs therapy for respiratory problems in older adults is challenging because of
physiologic changes that occur with the aging process. The nurse must keep in
mind that being frail and elderly places the patient at a higher risk of developing
serious adverse drug effects, thus, compromising the older adultsÊ health.
Table 4.7 discusses the management of drug therapy in the elderly.
"

SYSTEM
"
Table 4.7: Management of Drug Therapy in the Elderly
Pharmacotherapeutics Pharmacotherapeutics for the elderly are similar to younger

adults.
Pharmacokinetics Age-related physiologic changes ultimately alter the

pharmacokinetics among the elderly. These changes affect
absorption, distribution, metabolism and excretion.
Absorption Absorption of drugs therapy will be altered because of

increased gastric pH, decreased absorption surface,
decreased blood flow and decreased GI motility.
Distribution Distribution of drugs therapy will be changed due to

decreased cardiac output, decreased total body water,
decreased lean body mass, decreased serum albumin,
increase in 1-acid glycoprotein and increase in body fat.
Metabolism Metabolism of drug therapy will decline gradually as aging

progresses. It is altered by decreased hepatic mass and
decreased hepatic blood flow. In the elderly, standard half-
life parameters are also inaccurate.
Excretion Excretion of drugs is crucially affected by efficiency of renal

function. This is mainly due to decreased renal blood flow,
decreased glomerular function and decreased tubular
secretion.
ACTIVITY 4.4
What do you think are the effects of aging on the liver and its functioning
in drug therapy? Discuss this with your coursemates in the myINSPIRE
online forum.
SELF-CHECK 4.4
Describe the pharmacokinetics processes of absorption, distribution,

metabolism and excretion of drug therapy in older adults.

SYSTEM
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 COPD is a permanent, chronic obstruction of the airways, of which major

causes are emphysema and chronic bronchitis. Both of these conditions cause
airway obstruction during expiration due to over inflation of the lungs, leading
to poor gas exchange. Bronchodilators are the best option of pharmacological
therapy in COPD.
 Asthma is a common condition that puts intense burden on healthcare

resources. Drug management for asthma includes 2 agonist, antimuscarinic
bronchodilators, theophylline, corticosteroids, cromolyns and leukotriene
receptors antagonist.
 Inflammation response can be due to various types of stimuli. Inflammation is

also worsened by the rupture of mast cells, such as in allergies. This will lead
to release of biochemical mediators like histamine, prostaglandins and
leukotrienes.
 Salicylates and prostaglandin synthetase inhibitors (PSI) drugs are commonly

used to treat inflammation and fever in various conditions, including
respiratory disorders.
 Providing nursing care to patients with respiratory drugs therapy is a

challenging task because the nurse must exercise caution to specific
precautions in all age groups, be they children, pregnant and breastfeeding
mothers or the elderly group. Safety alert is essential because these groups
have different changes in the pharmacokinetics, pharmacotherapeutics,
absorption, distribution, metabolism and excretion of the drugs therapy.
"
Absorption Chronic obstructive pulmonary disease

Allergies Corticosteroids
Antihistamine Exacerbation
2 agonist Leukotriene receptor antagonist
Bronchodilator Metabolism

SYSTEM
"

British Thoracic Society, & Scottish Intercollegiate Guidelines Network. (2014).

British guideline on the management of asthma: A national clinical guideline.
London, England: BTS & SIGN.
Malaysian Thoracic Society. (1996). Guidelines on management of adult asthma:

A consensus statement of the Malaysian Thoracic Society. The Medical
Journal of Malaysia, 51(1), 114ă128. Retrieved from http://e-mjm.org/
1996/v51n1/ Adult_Asthma.pdf

of chronic obstructive pulmonary disease (2nd ed.). Retrieved from
World Health Organization, World Bank, & Harvard School of Public Health.
(1996). The global burden of disease: A comprehensive assessment of
mortality and disability from diseases, injuries, and risk factors in 1990 and
projected to 2020. In C. J. L. Murray, & A. D. Lopez (Eds.). Cambridge, MA:
Harvard School of Public Health. Retrieved from http://apps.who.int/
iris/bitstream/10665/41864/1/0965546608_eng.pdf

Topic
" " "
"
"  Pharmacotherapy
"
"
for Drugs of
5
"
"
"
"
Gastrointestinal,
"
"
"
Endocrine and
"
"
"
Other Conditions
"
" LEARNING OUTCOMES
"
" 1. Explain the specific precautions for medications that relate to upper
" and lower gastrointestinal tracts;
"
" 2. Differentiate the signs and symptoms of hyperglycaemia and
" hypoglycaemia;
" 3. Explain the use of the antiviral, antifungal and antiprotozoal drugs;
"
" 4. State the six mechanisms of action of antimicrobial drugs;
" 5. Describe the different strategies in chemotherapy; and
"
" 6. Explain the function of alkylating agents and antitumor antibiotics.
"
 INTRODUCTION
In this subtopic, we will discuss complications that relate to the gastrointestinal
(GI) system, endocrine system and other common conditions. Then, the discussion
will focus on types of drugs used for viral, bacterial, fungal, protozoan and
helminth infections in the human body. In the last subtopic, we will discuss drugs
for neoplasia.

TOPIC 5 PHARMACOTHERAPY FOR DRUGS OF GASTROINTESTINAL,  93
ENDOCRINE AND OTHER CONDITIONS
"
"
5.1 SPECIAL PRECAUTIONS FOR
MEDICATIONS RELATED TO SPECIFIC
SYSTEMS
In this subtopic, we will look into the special precautions to be taken for
medications related to the gastrointestinal (GI) system, focusing on the upper and
lower GI tract and the endocrine system.
5.1.1 Gastrointestinal System

For the GI tract, we will divide our discussion into upper GI and lower GI drugs.
Let us first look at the drugs for the upper GI tract.
Drugs for the upper GI tract include conditions such as gastroesophageal reflux
disease (GERD), Helicobacter pylori (H. Pylori) infection, peptic ulcer disease
(PUD) and pancreatitis. Table 5.1 outlines the most common drug classes and
examples of drugs for the respective classes used to treat disorders of the upper GI
tract.
Table 5.1: Common Drug Classes for Upper GI Tract
Drugs Classes Examples of Drugs
Antibiotic to treat  Amoxicillin

Helicobacter pylori infection
 Clarithromycin
 Metronidazole
 Tetracycline
Proton pump inhibitors  Omeprazole

(PPIs)
 Lansoprazole
 Pantoprazole
 Esomeprazole
Histamine-2 receptor  Ranitidine

antagonists (H2RAs)
 Cimetidine
 Famotidine
 Nizatidine
 Misoprostol
" "

94  TOPIC 5 PHARMACOTHERAPY FOR DRUGS OF GASTROINTESTINAL,
"
"
Antacids  Aluminium hydroxide with magnesium hydroxide
 Aluminium compounds
 Magnesium compounds
 Calcium carbonate
 Sodium bicarbonate
Prokinetic agents  Metoclopramide

 Cisapride
Digestive enzymes  Pancrelipase

 Pancreatin
Lipase inhibitors  Orlistat

 Adrenergic drugs
 Amphetamines
 Antidepressants
Antiemetics (serotonin  Ondansetron

receptor antagonists)
 Dolasetron
 Granisetron
 Antidopaminergics
 Anticholinergics
 Cannabinoids
 Glucocorticosteroids
Gallstone-solubilising agents  Ursodiol

 Monoctanoin
Now, let us look at the special precautions to be taken for the following drugs used
for the upper GI tract:
(a) Proton-pump Inhibitors (PPIs)

Proton-pump Inhibitors (PPIs) do cause hypergastrinemia, which is a
condition where there is an increased presence of the gastrin hormone in the
stomach. Hypergastrinemia will lead to hyperplasia and atrophic gastritis
especially in patients with H. Pylori infection with markedly increase of
gastrin levels.

"
"
Pneumonia is a potential adverse effect, which is associated to PPIs. This is
due to the increase in bacterial colonisation of the stomach and respiratory
tract when gastric acidity is reduced. Separately, in elderly patients, PPIs,
especially omeprazole, will increase the risk of fractures. This is because as
we age, our gastric pH will increase, but omeprazole will augment the
already elevated gastric pH even further. In theory, increase in gastric pH
will inhibit the absorption of calcium, thus, explaining why the risk of
fracture increases. Consequently, bone density test is required in elderly
patients with long-term omeprazole therapy. Calcium citrate
supplementation is essential for this group of patients to reduce the risk of
osteoporotic fractures.
In order to maximise the therapeutic effects of PPIs, we got to make sure that
the patient does not crush or chew the capsule. This is because doing so will
alter the absorption rate and reduce the effectiveness of the drug. PPIs should
be taken one hour before meals to ensure optimal therapeutic effects.
(b) Histamine-2 Receptor Antagonists (H2RAs)

Histamine-2 Receptor Antagonists (H2RAs) drugs such as ranitidine should
be used with caution in patients with gastric ulcers because the drugs will
mask the symptoms of GI cancer temporarily. Therefore, it is advisable to
explore any complaints of dyspepsia, nausea and vomiting, dark and tarry
stools, hepatic dysfunction, or any renal impairment when a patient is
consuming ranitidine.
In order to maximise the effects of ranitidine, it should be given at least two

hours apart from antacids. However, we should exercise caution when
administering cimetidine as it is known to interact with many drugs.
For example, cimetidine should not be administered concurrently with
phenytoin as it decreases the hepatic metabolism of the phenytoin.
(c) Antacids
Antacids that contain only aluminium as their active ingredient will cause
constipation, while antacids with solely magnesium as their active ingredient
will cause diarrhoea. Therefore, taking antacids that have a combination of
aluminium and magnesium will balance the side effects.
Do you know why antacids are commonly found in liquid preparation form?
The reason is that the liquid form will cause rapid action, thus, we must
always remember to remind patients to shake well the suspensions before
use. However, if the antacids are in tablet form, the patient should be advised
to chew the tablet thoroughly before swallowing and followed by drinking a
glass of water. For the best therapeutic effects, tablet antacids should be
administered one to three hours after meals or at bedtime.
"
"
(d) Prokinetic Agents
Prokinetic agents are given to increase gastrointestinal motility and
frequency of intestinal contractions to relieve distension, bloating, heartburn
and constipation. In order to maximise the therapeutic effects of a prokinetic
agent, it should be given 30 minutes before meals. However, patients should
be alert of „extrapyramidal symptoms‰ (involuntary movements of the
limbs, facial grimacing, or rhythmic protrusion of the tongue, see Figure 5.1).
If the symptoms occur, there are drugs to reverse them, such as
diphenhydramine (Benadryl) 50mg intramuscularly, or benztropine
(Cogentin) 1 to 2mg intramuscularly.
Figure 5.1: Extrapyramidal symptoms

Source: https://www.studyblue.com/notes/note/n/antipsychotics-and-anxiolytic-
drugs-ch-26/deck/14403230
"

"
"
Drugs for lower GI tract are given to relieve conditions such as flatus, diarrhoea,
constipation, irritable bowel syndrome (IBS) and inflammatory bowel disease
(IBD). Table 5.2 highlights the common drug classes and examples of drugs for the
respective classes used for the lower GI tract.
Table 5.2: Common Drugs for Lower GI Tract
Drug Classes Examples of Drugs
Antiflatulents  Charcoal
 Simethicone
Antidiarrhoea  Diphenoxylate hydrochloride with atropine

sulphate
 Loperamide
 Bismuth subsalicylate
 Kaolin and pectin
Laxatives  Magnesium hydroxide/sulphate/citrate

 Lactulose
 Glycerine suppository
 Bisacodyl
 Mineral oil
 Psyllium
 Castor oil
Drugs to treat Irritable  Alosetron

Bowel Syndrome
 Lubiprostone
 Dicylomine
Drugs to treat  Mesalamine

Inflammatory Bowel
 Balsalazide
Disease
 Olsalazide
"

"
"
Now, let us look at the special precautions to be taken for the following drugs used
for lower GI tract:
(a) Antidiarrhoea
For antidiarrheal agents such as diphenoxylate HCL with atropine sulphate,
due to massive dilation and atony of the colon, the patients should be
assessed and reported for toxic megacolon like abdominal distension and
pain. Atropine is added to this drug to discourage abuse. Separately, these
drugs are contraindicated for children or adolescents as bismuth
subsalicylate leads to the possibility of Reye syndrome.
(b) Laxatives
To treat constipation, laxatives usage should be used with caution to avoid
incidents of overactive bowels like cramps, diarrhoea and nausea. Laxatives
are for short-term use only. Any long-term use will lead to electrolyte
imbalance. In pregnancy, use of laxatives should be cautioned because it will
induce premature labour. Therefore, it is recommended that pregnant
women with constipation use other preventive methods such as drinking
sufficient water (at least eight glasses a day) and consuming adequate fibre
in their diet.
(c) Drugs to Treat Irritable Bowel Syndrome

Patients on drugs for Irritable Bowel Syndrome should be advised to report
immediately for any constipation or signs of ischemic colitis such as bleeding
from the rectal tract, bloody diarrhoea or abdominal pain.
(d) Drugs to Treat Inflammatory Bowel Disease

Drugs for treating Inflammatory Bowel Disease are found in a combination
of 5-aminosalicylic acid, corticosteroids and antibiotics. Therefore, as a
special precaution, patient should be reminded to report immediately if there
is any blood dyscrasia and monitor renal and liver profiles closely.

"
"
SELF-CHECK 5.1
1. Explain the special precautions to be taken for upper GI tract using

proton-pump inhibitors (PPIs), histamine-2 receptor antagonists
(H2RAs) and antacids.
2. Explain the special precautions to be taken for lower GI tract using

antidiarrheal agents and laxatives.
ACTIVITY 5.1
1. Do some research and find out the advantage of combining

aluminium hydroxide with magnesium hydroxide as an antacid.
Share your findings in the myINSPIRE online forum.
2. Mr J is allergic to aspirin. Why do you think bismuth subsalicylate

is contraindicated for him to treat his diarrhoea?
3. Mr K, is admitted for gastric ulcer. He has history of seizure

disorder but has maintained seizure-free by using phenytoin.
As a health care provider, what are you going to teach your junior
colleague about interaction of certain Histamine 2 Receptor
Blockers with phenytoin? What is the name of the drug? Discuss
and share your answers in the myINSPIRE online forum.
5.1.2 Endocrine System

Now, we will discuss certain common conditions of the endocrine system such as
diabetes insipidus (DI), diabetes mellitus (DM) and diabetic ketoacidosis (DKA).
Let us look into the following explanations for these three conditions:
(a) Diabetes Insipidus

Drugs which are commonly used to treat diabetes insipidus are
desmopressin (DDAVP), vasopressin.

"
"
(b) Diabetes Mellitus
Diabetes mellitus can be classified according to its aetiology as follows:
(i) Type I diabetes (also known as juvenile onset diabetes); or
(ii) Type II diabetes (also known as adult onset diabetes).
In this subtopic, drug treatments related to type II diabetes are emphasised,

as this is the more common type of diabetes prevalent in the community.
Despite the advances in medical and pharmacology, diabetes mellitus
remains a major medical challenge in Malaysia. As healthcare professionals,
it is important to teach proper health education to the patients and the family
about signs and symptoms of diabetes and also the serious complications
such as hyperglycaemia and hypoglycaemia such as irritability, confusion,
nervousness, weakness and hunger. They should be alerted on simple
treatments for emergency relieve from hypoglycaemia such as usage of small
amounts of sugar (hard candy, orange juice, or a teaspoon of sugar).
Figure 5.2 shows the process of insulin synthesis and release in Type II
diabetes.
Figure 5.2: Insulin synthesis and release

Source: http://simonrdownes.com/2014/03/

"
"
Table 5.3 outline the drugs commonly used in treating diabetes mellitus.
Table 5.3: Drugs Used in Treating Diabetes Mellitus
Drugs Specific Precautions
Insulin  Only to be given through injection (SubQ, IM or IV) because

oral route will be inactivated by digestive enzyme.
 Injection sites should be rotated.
 Pay attention to insulin toxicity such as somogyi effect/dawn
phenomenon (rapid decrease of blood sugar level at night),
nonketotic hyperglycemia and coma.
Oral  The two main categories of oral hypoglycaemic agents are as

hypoglycaemic follows:
agents
⁄ Sulfonylureas (e.g. glyburide and glipizide); and
⁄ Non-sulfonylureas (for example, metformin, acarbose,
sitagliptin and rosiglitazone).
 Lead to hypoglycaemic reactions if drug overdose, drug
interaction or inadequate food intake.
 Be mindful if the patient is fasting for surgery.
Glucose-elevating  Glucose-elevating agents include glucagon, diazoxide and

agents glucose.
 Teach family members the importance of quick intervention
when severe hypoglycaemia occurs. This is to prevent central
nervous system damage.
"

"
"
Now, let us look at Figure 5.3, which shows the signs and symptoms of
hyperglycaemia and hypoglycaemia.
Figure 5.3: Signs and symptoms of hyperglycaemia and hypoglycaemia

Source: https://www.pinterest.com/pin/90353536249046859/
(c) Diabetic Ketoacidosis (DKA)

DKA is also known as hyperosmolar hyperglycaemia non-ketotic syndrome.
DKA is a serious acute complication of diabetes mellitus that contributes to
mortality among diabetes patients. DKA primarily occurs in type I diabetes
but can also happen in type II diabetes. Patients and family members should
be taught on signs and symptoms of hyperglycaemia. Treatment includes
proper rehydration and also drug therapy to lower the blood glucose of the
victim. For diabetes patients receiving insulin therapy, fasting
hyperglycaemia will occur in two situations; dawn phenomenon and
Somogyi effect (refer to Table 5.4).
"

"
"
Table 5.4: Dawn Phenomenon and Somogyi Effect in Hyperglycaemia
Two Situations in Blood Glucose

Aetiology Treatment
Hyperglycaemia Levels
Dawn Blood glucose It is believed that Providing larger dose of
Phenomenon levels are the release of intermediate-acting
highest between growth hormone insulin at bedtime to
5am to 6am. overnight lead to prevent early morning
elevated blood elevations of blood
glucose levels. glucose levels.
Somogyi effect Blood glucose Precipitating Lowering the insulin
levels are factors are actually dose, and increasing the
highest early in hypoglycaemic dietary intake at bedtime.
the morning. events after
midnight.
Overcompensated
by the body
resulting in
rebound
hyperglycaemia.
Figure 5.4 shows the difference in blood glucose concentration levels that
result from the Dawn phenomenon and the Somogyi effect in hyperglycaemia.
Figure 5.4: Dawn phenomenon and Somogyi effect in hyperglycaemia

Source: http://www.medpreponline.com/2012/11/dawn-phenomenon-and-somogyi-
effect.html

"
"
Now, let us look at Figure 5.5 to explore the algorithm to follow the specific
pathway for dealing with a hyperglycaemic emergency.
Figure 5.5: Algorithm for hyperglycaemia in DKA

Source: Royal College of Nursing (2016)
SELF-CHECK 3.2

"
"
So far, we have covered the drugs to treat the common conditions of the GI tract
and endocrine systems. The next subtopic will deal with slightly different types of
information, but they are still useful information to your pharmacological learning
experience.
SELF-CHECK 5.2
1. What effect does insulin have on blood glucose levels?
2. Why canÊt insulin be given orally? Explain.
3. Distinguish between the signs and symptoms of hyperglycaemia

and hypoglycaemia.
5.2 DRUGS FOR BACTERIAL, VIRAL, FUNGAL,

PROTOZOAN AND HELMINTH
INFECTIONS
Drugs used to treat infections are called antimicrobials, anti-infectives or
antibiotics. Penicillin was the first effective antimicrobial drug discovered by Sir
Alexander Flemming in 1928. Now, there are numerous types of antimicrobial
drugs used to treat infections. The major classifications of antimicrobial drugs
include antibacterial drugs, antiviral drugs, antifungal drugs, antiparasitic drugs,
antiprotozoal drugs and antihelminthic drugs.
Let us look into the following descriptions of some of the main types of
antimicrobial drugs:
(a) Antibacterial Drugs

Antibacterial drugs (antibiotics) are further divided into the following
categories:
(i) Narrow-spectrum Drug

This category of drugs is effective against a few types of bacteria.
(ii) Broad-spectrum Drug

This category of drugs is effective against many types of bacteria.

"
"
(b) Antiviral Drugs
Antivirals are used to treat herpes, cytomegalovirus, HIV and AIDS and also
influenza. Common examples of antiviral drugs are Acyclovir, DHPG,
Foscavir, Amprenavir, Ritonavir, Flumadine, Virazole and others.
(c) Antifungal Drugs

Antifungals are used to treat tinea infections (a fungal infection caused by
ringworm), candida infections, histoplasmosis and aspergillus fumigates.
(d) Antiprotozoal Drugs

Antiprotozoal drugs are used to treat parasitic infestations. Examples of
antiprotozoal drugs like chloroquine, pyrimethamine and quinine are used
to treat malaria and toxoplasmosis. On the other hand, antihelminthics, such
as Mebendazole, Pyrantel, Albendazole and Praziquentel are used to treat all
worm infections.
Antimicrobial drugs can also be classified by the mechanism of action. All

antimicrobial drugs work in the following different ways:
(a) Inhibition of bacterial cell wall synthesis;
(b) Inhibition of protein synthesis;
(c) Inhibition of nucleic acid synthesis;
(d) Disruption of cell wall permeability;
(e) Inhibition of metabolic pathways (antimetabolites); and
(f) Inhibition of viral enzymes.
"

"
"
Table 5.5 outlines the earlier mentioned mechanisms of action with examples of
antimicrobials for each group.
Table 5.5: Classifications of Antimicrobial Drugs by Mechanism of Action
Mechanism of Actions Antimicrobials

Inhibit cell wall synthesis  Cephalosporins
 Daptomycin
 Penicillins
 Vancomycin
Inhibit protein synthesis  Aminoglycosides
 Chloramphenicol
 Clindamycin
 Erythromycin
 Tetracyclines
Inhibit nucleic acid synthesis  Fluoroquinolones
 Rifampin
Disrupt cell membrane permeability  Polymyxins
 Polyene antimicrobials
 Imidazole antifungal agents
Work as an antimetabolite  Sulfonamides
 Trimethoprim
Inhibit viral enzymes  Acyclovir
 Saquinavir
Now, let us learn more about the following antibiotics:
(a) Aminoglycosides
Examples are Amikacin sulphate, Gentamycin sulphate, Neomycin sulphate
and many more. Used to treat infections caused by Acinetobacter, E. coli,
Klebsiella pneumonia/pseudomonas/proteus, Salmonella and
Staphylococcus.

"
"
(b) Cephalosporins
Cephalosporins are further divided into first, second, third and fourth
generation. Used to treat infections caused by E. coli, P. mirabilis,
K. pneumonia, Neiserria gonorrhoeae, syphilis, pelvic inflammatory disease,
respiratory infections, urinary tract infections, skin infections and
prophylaxis to prevent bone infections in orthopaedic surgery.
(c) Fluoroquinolones
Examples are Ciprofloxacin, Ofloxacin, Enoxacin, Norfloxacin and many
more. Used to treat infections caused by H. influenzae, S. pneumoniae,
Moraxella catarrhalis, lower respiratory tract infections, acute sinusitis,
urinary tract infections, S. aureus, S. epidemidis, N.gonorrhoeae, otitis media
and many more.
(d) Macrolides and Lincosamides

Examples are Azithromycin, Clarithromycin, Erythromycin and others.
Used to treat infections caused by Streptococcus, Haemophilus, syphilis,
gonorrhoea, mycoplasma infections, H. Pylori, genitourinary infections and
many more.
(e) Monobactams
Common drugs are Imipenem/cilastatin, vancomycin and Aztreonam. Used
to treat infections caused by gram-negative organisms, P. aeruginosa,
septicaemia, K. pneumoniae, P. aeruginosa, intra-abdominal infections,
meningitis, H. pylori and nosocomial pneumonia.
(f) Sulphonamides
Examples are Bactrim, Gastrisin and Azulfidine. Used to treat UTIs,
rheumatoid arthritis, toxoplasmosis, brain abscesses and C. trachomatis
infections.
(g) Tetracyclines
Examples are Tetracycline, Declomycin, Oxytetracycline and Minocycline.
Effective against most chlamydia, mycoplasma, rickettsiae, cholera and
protozoa.
SELF-CHECK 5.3
1. Briefly explain the use of antiviral, antifungal and antiprotozoal

drugs.
2. State the six mechanisms of action of antimicrobial drugs.

"
"
5.3 DRUGS FOR NEOPLASIA
Statistics by the National Cancer Society Malaysia (2016) reported that about
21,773 Malaysians are diagnosed with cancer but estimates that almost 10,000 cases
are unregistered every year. The five top cancers affecting both the male and
female population in Malaysia are breast, colorectal, lung, cervical and
nasopharyngeal cancers (National Cancer Society Malaysia, 2016).
The role of chemotherapy can be categorised for different strategies of treatment,

namely adjuvant therapy, induction therapy, consolidation therapy, intensification,
maintenance, neoadjuvant therapy and palliative therapy (refer to Table 5.6).
Table 5.6: Treatment Strategies of Chemotherapy
Treatment Strategies
Adjuvant therapy Involves short course of high dose drugs, usually combination of
drugs. Administered after radiation or surgery. Purpose is to
destroy residual tumour cells and prevent recurrence.
Induction therapy Also called the starting phase of any chemotherapy. Induction
consists of high dose drugs combination. The purpose is to induce
a complete response during curative regimen initiation.
Consolidation This therapy is given after the induction therapy and has
therapy achieved complete remission. It can be repeated to increase to
prolong the patient survival by increasing the probability of cure.
Intensification In this therapy, the same drugs used for induction therapy are
given at higher dose; or, other drugs at higher dose. The purposes
are to improve the chances of cure and longer remission.
Maintenance It involves low dose cytotoxic drugs in long-term patient who are
in complete remission. The purpose is to delay the re-growth of
any residual cancer cells.
Neoadjuvant It involves administration of chemotherapy drugs before any
therapy surgery or radiation. The purposes are to reduce the tumour
burden and shrinking of the tumour.
Palliative therapy When cure is not achievable, this therapy involves administered
of chemotherapy drugs to control the symptoms, provide comfort
and improve patientÊs quality of life.
"

"
"
We will later be discussing cell-cycle nonspecific antineoplastic agents, namely
alkylating agents, nitrosoureas, antitumor antibiotics, and also hormones and
hormones antagonists. All this drugs are given as bolus doses to the patient
because they will cause cell death independently at the proliferative phase of the
cell. Figure 5.6 shows the different phases of cell cycle.
Figure 5.6: Phases of normal cell cycle

Source: http://www.bristol.k12.ct.us/page.cfm?p=7093
"

"
"
Now, let us look at the common cancer chemotherapy agents and their examples
(see Table 5.7).
Table 5.7: Cancer Chemotherapy Agents
Cancer Chemotherapy Agents Examples

Alkylating agents  Cyclophosphamide
 Busulfan
 Chlorambucil
 Melphalan
 Carboplatin
 Cisplatin
 Oxaliplatin
Nitrosoureas  Lomustine
 Streptozocin
Antitumor antibiotics  Doxorubicin
 Mitoxantrone
 Bleomycin
Hormones and hormones antagonists  Tamoxifen
 Adrenocorticoids
 Androgens
 Oestrogens
 Progestins
The following are some explanation about the common cancer chemotherapy
agents:
(a) Alkylating Agents

The most widely used alkylating agent is cyclophosphamide. This is because
of its properties with broad spectrum of antitumor activity. Due to incidence
of haemorrhagic cystitis, vigorous hydration with at least 2L of fluids a day
is important to the patient with this drug therapy. However, in high doses,
agent mesna should be considered. Emesis and reversible hair loss are
common side effects for alkylating agents.

"
"
(b) Nitrosoureas
Example of frequently used nitrosoureas agents are carmustine and
streptozocin. Carmustine is widely used in palliative therapy for brain
tumours, multiple myeloma, HodgkinÊs and non-HodgkinÊs lymphoma.
Acute emesis (vomiting within 24 hours of chemotherapy) and delayed
emesis (vomiting within 24 hours of chemotherapy) are the primary adverse
effects of nitrosoureas.
(c) Antitumor Antibiotics

Antitumor antibiotics act by preventing the duplication and separation
of DNA-RNA chains, thus, further synthesis is inhibited. Doxorubicin is
mostly used among antitumor antibiotics. A major adverse effect of
these drugs is cardiotoxicity. Please take note that digoxin, heparin and
barbiturates will interact with doxorubicin in different ways (refer to
Table 5.8).
Table 5.8: Interaction of Doxorubicin with Other Agents
Agents Effects and Significance Nursing Management

Digoxin Decreased serum levels and Monitor serum digoxin levels.
therapeutic effect of digoxin.
Heparin Precipitates formation if both Administer doxorubicin and heparin
agents are mixed together. separately.
Barbiturates Increased plasma clearance of To notify the physician for dosage
doxorubicin. alteration consideration.

"
"
(d) Hormones and Hormones Antagonists
This group of drugs are mostly recognised for treating neoplasms that
originate in hormonally mediated tissues such as prostate and breast cancers.
Tamoxifen is indicated as first-line therapy for advanced breast cancer.
Tamoxifen has interactions with other agents like oral anticoagulants and
bromocriptine (refer to Table 5.9).
Table 5.9: Agents that Interact with Tamoxifen
Agents Effect and Significance Nursing Management

Oral Increased risk of bleeding Monitor prothrombin time and monitor
anticoagulants for signs of bleeding
Bromocriptine Increased serum levels Monitor tamoxifen serum levels
One of the major advances in cancer treatment is combination chemotherapy,

which involves usage of two or more drugs administered simultaneously and is
proven effective against tumour cells. Combination chemotherapy is superior
because of the following reasons:
(a) It has maximum cells-kill within the range of toxicity that is tolerated by the
patient;
(b) It has a broader range of coverage against cell lines, especially in a

heterogeneous tumour population; and
(c) It has minimal or slow development of new resistant cell groups.
SELF-CHECK 5.4
1. What are the different strategies in chemotherapy? Briefly describe

any three of the strategies.
2. Explain the function of alkylating agents and antitumor antibiotics.
ACTIVITY 5.2
Why do you think combination chemotherapy is gaining popularity in

advanced cancer therapy? Discuss your answer with your coursemates
in the myINSPIRE online forum.

"
"
 Drugs for upper GI tract are administered for conditions such as

gastroesophageal reflux disease (GERD), Helicobacter pylori (H. Pylori)
infection, peptic ulcer disease (PUD) and pancreatitis.
 Drugs for lower GI tract are administered for conditions such as flatus,
diarrhoea, constipation, irritable bowel syndrome (IBS) and inflammatory
bowel disease (IBD).
 Prokinetic agents, in order to maximise the effects, should be given 30 minutes

before meals. However, patient should be alert of extrapyramidal symptoms.
 In cases of diabetes mellitus, the family members should be alerted of simple

treatment for hypoglycaemia such as administering small amounts of fast
absorbing carbohydrates.
 In DKA, patient and family members should be taught of signs and symptoms
of hyperglycaemia. Treatment includes proper rehydration and also drugs
therapy to lower the blood glucose of the victim.
 For diabetes patients receiving insulin therapy, fasting hyperglycaemia will

occur in two types: dawn phenomenon and somogyi effect.
 Antibacterial drugs (antibiotics) are further divided into narrow-spectrum and

broad-spectrum. All antimicrobial drugs work in different ways.
 Adjuvant therapy, induction therapy, consolidation therapy, intensification,

maintenance, neoadjuvant therapy, and palliative therapy are different roles
of chemotherapy.
 Combination therapy is proven to be more effective than a single therapeutic

agent.
 Always remember that effectiveness of treatment can be assessed by the

clinical assessment of the following: relief of symptoms with least side effects;
CBC counts, serum urea, creatinine and electrolyte levels, incidents of
infections are reduced, appropriate management of GIT stress without weight
loss, lack of malaise, fatigue and alopecia.

"
"
Antimicrobials Hypoglycaemia
Chemotherapy Inflammatory bowel disease
Dawn phenomenon Irritable bowel syndrome
Endocrine system Lower GI tract
Extrapyramidal symptoms Somogyi effect
Hyperglycaemia Upper GI tract

Ministry of Health Malaysia. (2009). Clinical practice guidelines:

Management of type 2 diabetes mellitus (4th ed.). Retrieved from
National Cancer Society Malaysia. (2016). Types of cancer. Retrieved from

http://www.cancer.org.my/quick-facts/types-cancer/
Royal College of Nursing. (2016). Emergency treatment for diabetes.

Retrieved from https://www2.rcn.org.uk/development/practice/cpd_
online_learning/diabetes_essentials/emergency_treatment

MODULE FEEDBACK
MAKLUM BALAS MODUL
If you have any comment or feedback, you are welcome to:
1. E-mail your comment or feedback to modulefeedback@oum.edu.my
OR
2. Fill in the Print Module online evaluation form available on myINSPIRE.
Thank you.
Centre for Instructional Design and Technology

(Pusat Reka Bentuk Pengajaran dan Teknologi )
Tel No.: 03-27732578
Fax No.: 03-26978702


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NBHS1303

Clinical Pharmacology and Toxicology

Copyright © Open University Malaysia (OUM)

Topic 1 Core Concepts of Pharmacology 1

Topic 2 Pharmacology and Adverse Effects of Drugs 22

Copyright © Open University Malaysia (OUM)

Topic 3 Pharmacotherapy for Conditions of the Cardiovascular System 50

Topic 4 Pharmacotherapy for Conditions of the Respiratory System 71

Copyright © Open University Malaysia (OUM)

Topic 5 Pharmacotherapy for Drugs of Gastrointestinal, Endocrine 92

Copyright © Open University Malaysia (OUM)

Copyright © Open University Malaysia (OUM)

Copyright © Open University Malaysia (OUM)

Copyright © Open University Malaysia (OUM)

COURSE GUIDE DESCRIPTION

As an open and distance learner, you should be acquainted with learning

Copyright © Open University Malaysia (OUM)

Table 1: Estimation of Time Accumulation of Study Hours

COURSE LEARNING OUTCOMES

Topic 1 introduces the core concepts of pharmacology. Medication administration

Copyright © Open University Malaysia (OUM)

Topic 2 discusses how the principles of drugs administration is essential to provide

Topic 3 explores pharmacotherapy for conditions of the cardiovascular system.

Topic 5 adds on to your knowledge on medications for gastrointestinal (GI)

Copyright © Open University Malaysia (OUM)

TEXT ARRANGEMENT GUIDE

Self-Check: This component of the module is inserted at strategic locations

Activity: Like Self-Check, the Activity component is also placed at various

Copyright © Open University Malaysia (OUM)

Adams, M. P., Holland, L. N., & Bostwick, P. M. (2014). Pharmacology for

Craig, G. P. (2015). Clinical calculations made easy: Solving problems using

Copyright © Open University Malaysia (OUM)

Karch, A. M. (2013). Focus on nursing pharmacology (6th ed.). Philadelphia, PA:

Ministry of Health Malaysia. (2006). National cardiovascular disease

Ministry of Health Malaysia. (2009). Clinical practice guidelines:

Ministry of Health Malaysia. (1996). Guidelines on management of adult asthma:

Ministry of Health Malaysia. (2009). Clinical practice guidelines: Management

TAN SRI DR ABDULLAH SANUSI (TSDAS)

Copyright © Open University Malaysia (OUM)

" Core Concepts of

Copyright © Open University Malaysia (OUM)

Pharmacology is a term derived from the Greek words pharmakon, meaning

Therapeutics is concerned with the prevention and cure of diseases as well as

1.1 CORE CONCEPTS OF PHARMACOLOGY

(a) Pharmacotherapeutics or Pharmacotherapy

Copyright © Open University Malaysia (OUM)

Importantly for healthcare providers, the application of pharmacokinetics in

This is where healthcare providers should be able to apply knowledge

The understanding of pharmacodynamics assists healthcare providers to

Copyright © Open University Malaysia (OUM)

Other common terms related to pharmacology are shown in Table 1.1.

Table 1.1: Descriptions of Common Terms Related to Pharmacology

1.2 ROUTES OF MEDICATION

Figure 1.1: The three common routes of medication administration

(i) Epicutaneous/transdermal or dermatologic;

(ii) Inhalation, such as asthma medications;

Copyright © Open University Malaysia (OUM)

(iii) Enema or suppositories ă vagina, rectum;

(iv) Eye drops/ophthalmic;

(v) Ear drops/otic; and

(i) Oral preparation ă Swallowing tablets, capsules, liquid and drops.

(iii) Nasogastric or gastrostomy tube ă Any medication prescribed for a

(i) Person administering must adhere to the aseptic technique during